Healthcare Provider Details

I. General information

NPI: 1407303662
Provider Name (Legal Business Name): ROBERT ALLEN REISCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TIFFANY LEEANNE REISCH

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19758 DAYTON HOLLOW LN
FERGUS FALLS MN
56537-7621
US

IV. Provider business mailing address

19758 DAYTON HOLLOW LN
FERGUS FALLS MN
56537-7621
US

V. Phone/Fax

Practice location:
  • Phone: 218-340-1359
  • Fax: 218-737-0028
Mailing address:
  • Phone: 218-340-1359
  • Fax: 218-737-0028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAPPLIED
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: