Healthcare Provider Details

I. General information

NPI: 1427271089
Provider Name (Legal Business Name): MILLE LACS ISANTI & SHERBURNE COS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 1ST ST
PRINCETON MN
55371-1502
US

IV. Provider business mailing address

140 BUCHANAN ST N STE. 150
CAMBRIDGE MN
55008-1638
US

V. Phone/Fax

Practice location:
  • Phone: 763-389-2422
  • Fax: 763-389-9142
Mailing address:
  • Phone: 763-689-3600
  • Fax: 763-689-3601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number8922892
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE K WYGANOWSKI
Title or Position: LSN
Credential:
Phone: 612-419-0211