Healthcare Provider Details

I. General information

NPI: 1912556937
Provider Name (Legal Business Name): SENIORWELL POD OF MINNESOTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S 5TH ST STE 1900
MINNEAPOLIS MN
55402-1267
US

IV. Provider business mailing address

2100 E LAKE COOK RD STE 1000
BUFFALO GROVE IL
60089-1999
US

V. Phone/Fax

Practice location:
  • Phone: 844-882-3127
  • Fax: 844-246-5875
Mailing address:
  • Phone: 844-882-3127
  • Fax: 844-246-5875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN MARONEY
Title or Position: CEO
Credential:
Phone: 844-882-3127