Healthcare Provider Details

I. General information

NPI: 1154696813
Provider Name (Legal Business Name): HEALTHSOURCE OF ST. PAUL- GRAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 GRAND AVE SUITE #114
SAINT PAUL MN
55105-3022
US

IV. Provider business mailing address

1053 GRAND AVE SUITE #114
SAINT PAUL MN
55105-3022
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-9247
  • Fax: 651-292-9257
Mailing address:
  • Phone: 651-292-9247
  • Fax: 651-292-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberDC4257
License Number StateMN

VIII. Authorized Official

Name: DR. CHRISTOPHER THOMAS DREWS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 651-292-9247