Healthcare Provider Details

I. General information

NPI: 1891729737
Provider Name (Legal Business Name): ALLERGY, ASTHMA AND IMMUNOLOGY CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4625 CHURCHILL ST SUITE 211
SHOREVIEW MN
55126-5868
US

IV. Provider business mailing address

4625 CHURCHILL ST SUITE 211
SHOREVIEW MN
55126-5868
US

V. Phone/Fax

Practice location:
  • Phone: 651-765-9800
  • Fax: 651-765-9801
Mailing address:
  • Phone: 651-765-9800
  • Fax: 651-765-9801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AUDREY D CECKO
Title or Position: OFFICE MANAGER
Credential:
Phone: 651-765-9800