Healthcare Provider Details

I. General information

NPI: 1003214149
Provider Name (Legal Business Name): COUNTY OF RENVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HEALTHY WAY
OLIVIA MN
56277-1117
US

IV. Provider business mailing address

6501 CITY WEST PKWY
EDEN PRAIRIE MN
55344-3248
US

V. Phone/Fax

Practice location:
  • Phone: 320-523-3477
  • Fax:
Mailing address:
  • Phone: 952-653-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: NATHAN BLAD
Title or Position: CEO
Credential:
Phone: 320-523-3477