Healthcare Provider Details

I. General information

NPI: 1073789939
Provider Name (Legal Business Name): THEODORE J. PIERZINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 S WALNUT ST STE 100
LA CRESCENT MN
55947-1319
US

IV. Provider business mailing address

33 S WALNUT ST STE 100
LA CRESCENT MN
55947-1319
US

V. Phone/Fax

Practice location:
  • Phone: 507-895-6666
  • Fax:
Mailing address:
  • Phone: 507-895-6666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1016047-1-CDT
License Number StateMN

VIII. Authorized Official

Name: MR. THEODORE J PIERZINA
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 507-895-6666