Healthcare Provider Details

I. General information

NPI: 1255169579
Provider Name (Legal Business Name): EDWARD TEMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23108 NIGHTINGALE ST NW
SAINT FRANCIS MN
55070-9640
US

IV. Provider business mailing address

23108 NIGHTINGALE ST NW
SAINT FRANCIS MN
55070-9640
US

V. Phone/Fax

Practice location:
  • Phone: 612-910-2857
  • Fax:
Mailing address:
  • Phone: 612-910-2857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberQB808212
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: