Healthcare Provider Details

I. General information

NPI: 1417554155
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: 10/06/2020
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
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: 763-432-7501
Mailing address:
  • Phone: 763-432-7655
  • Fax: 763-432-7501

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: MR. MICHAEL MILLER
Title or Position: BOARD MEMBER
Credential:
Phone: 763-432-7655