Healthcare Provider Details

I. General information

NPI: 1447901624
Provider Name (Legal Business Name): ZACHARY RYLAN LOMENDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2022
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7760 FRANCE AVE S FL 11
MINNEAPOLIS MN
55435-5930
US

IV. Provider business mailing address

4725 AMBER VALLEY PKWY S STE B
FARGO ND
58104-8614
US

V. Phone/Fax

Practice location:
  • Phone: 612-594-8405
  • Fax: 855-568-2494
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA0948
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: