Healthcare Provider Details

I. General information

NPI: 1558602607
Provider Name (Legal Business Name): MINNESOTA MEDICAL IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2013
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date: 09/26/2014
Reactivation Date: 10/08/2014

III. Provider practice location address

715 FLORIDA AVE S SUITE 205
GOLDEN VALLEY MN
55426-1719
US

IV. Provider business mailing address

715 FLORIDA AVE S SUITE 205
GOLDEN VALLEY MN
55426-1719
US

V. Phone/Fax

Practice location:
  • Phone: 612-354-7905
  • Fax: 612-315-4165
Mailing address:
  • Phone: 612-354-7905
  • Fax: 612-315-4165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: MISS ASHLEY NEWMAN
Title or Position: MANAGER - HSI
Credential:
Phone: 612-964-1810