Healthcare Provider Details

I. General information

NPI: 1396442745
Provider Name (Legal Business Name): CORNER MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 02/15/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1267 S POKEGAMA AVE STE 7
GRAND RAPIDS MN
55744-4208
US

IV. Provider business mailing address

2730 NEVADA AVE N
NEW HOPE MN
55427-2807
US

V. Phone/Fax

Practice location:
  • Phone: 800-777-8390
  • Fax:
Mailing address:
  • Phone: 763-535-5335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: TAMMI LEE BAGSTAD
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 763-540-6119