Healthcare Provider Details

I. General information

NPI: 1023746930
Provider Name (Legal Business Name): CENTER FOR RESTORATIVE SURGERY AT MAPLE GROVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13601 80TH CIR N STE 100
MAPLE GROVE MN
55369-8906
US

IV. Provider business mailing address

13601 80TH CIR N STE 100
MAPLE GROVE MN
55369-8906
US

V. Phone/Fax

Practice location:
  • Phone: 763-432-7655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL MILELR
Title or Position: REGIONAL VICE PRESIDENT OPERATIONS
Credential:
Phone: 612-518-5185