Healthcare Provider Details

I. General information

NPI: 1629373246
Provider Name (Legal Business Name): TOTAL HEALTHCARE AND PHYSICAL MEDICINE PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 HAMLINE AVE N STE. 111
ROSEVILLE MN
55113-4236
US

IV. Provider business mailing address

2151 HAMLINE AVE N STE. 111
ROSEVILLE MN
55113-4236
US

V. Phone/Fax

Practice location:
  • Phone: 651-636-5560
  • Fax: 651-636-4406
Mailing address:
  • Phone: 651-636-5560
  • Fax: 651-636-4406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number30851
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13954
License Number StateMN

VIII. Authorized Official

Name: MS. KOULA VANG
Title or Position: OFFICE MANAGER
Credential:
Phone: 651-636-5560