Healthcare Provider Details

I. General information

NPI: 1477680718
Provider Name (Legal Business Name): SOUTHDALE ALLERGY AND ASTHMA CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W 65TH ST #221
MINNEAPOLIS MN
55435-1721
US

IV. Provider business mailing address

4010 W 65TH ST #221
MINNEAPOLIS MN
55435-1721
US

V. Phone/Fax

Practice location:
  • Phone: 952-926-7630
  • Fax: 952-926-2116
Mailing address:
  • Phone: 952-926-7630
  • Fax: 952-926-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number23905
License Number StateMN

VIII. Authorized Official

Name: MRS. PAULINE SCHINDELDECKER
Title or Position: OFFICE MANAGER
Credential:
Phone: 952-926-7630