Healthcare Provider Details

I. General information

NPI: 1750383808
Provider Name (Legal Business Name): JENGYU LAI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 WELLNER DR NE
ROCHESTER MN
55906-8427
US

IV. Provider business mailing address

3070 WELLNER DR NE
ROCHESTER MN
55906-8427
US

V. Phone/Fax

Practice location:
  • Phone: 507-218-3095
  • Fax: 507-218-3097
Mailing address:
  • Phone: 507-218-3095
  • Fax: 507-218-3097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number635
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: