Healthcare Provider Details

I. General information

NPI: 1063568574
Provider Name (Legal Business Name): FRASER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W 64TH ST
RICHFIELD MN
55423-1001
US

IV. Provider business mailing address

2400 W 64TH ST
RICHFIELD MN
55423-1001
US

V. Phone/Fax

Practice location:
  • Phone: 612-861-1688
  • Fax: 612-861-6050
Mailing address:
  • Phone: 612-861-1688
  • Fax: 612-861-6050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES D OLSON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 612-798-8320