Healthcare Provider Details

I. General information

NPI: 1427130467
Provider Name (Legal Business Name): BRENDA GAIL GREWELL L AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 04/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 LOUISA AVE
MOUNDS VIEW MN
55112
US

IV. Provider business mailing address

2650 LOUISA AVE
MOUNDS VIEW MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 612-850-1305
  • Fax: 763-780-6207
Mailing address:
  • Phone: 612-850-1305
  • Fax: 763-780-6207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1204
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: