Healthcare Provider Details

I. General information

NPI: 1730363698
Provider Name (Legal Business Name): GILLETTE CHILDREN'S SPECIALTY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 UPLAND LANE NORTH SUITE 220
MAPLE GROVE MN
55369
US

IV. Provider business mailing address

200 UNIVERSITY AVE E
SAINT PAUL MN
55101-2507
US

V. Phone/Fax

Practice location:
  • Phone: 651-291-2848
  • Fax:
Mailing address:
  • Phone: 651-291-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateMN

VIII. Authorized Official

Name: PATRICK NOLAN
Title or Position: CFO
Credential:
Phone: 651-312-3105