Healthcare Provider Details

I. General information

NPI: 1003316852
Provider Name (Legal Business Name): MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2018
Last Update Date: 07/17/2024
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 ROOSEVELT RD
SAINT CLOUD MN
56301-6153
US

IV. Provider business mailing address

3475 PLYMOUTH BLVD STE 200
PLYMOUTH MN
55447-1539
US

V. Phone/Fax

Practice location:
  • Phone: 763-577-2484
  • Fax: 763-577-1375
Mailing address:
  • Phone: 763-577-2484
  • Fax: 763-577-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TIA A REICHERT
Title or Position: CHRO/CLINIC ADMIN
Credential:
Phone: 763-577-2484