Healthcare Provider Details

I. General information

NPI: 1811757248
Provider Name (Legal Business Name): HAILEY PHAM DCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6250 EXCELSIOR BLVD STE 103
ST LOUIS PARK MN
55416-2735
US

IV. Provider business mailing address

6250 EXCELSIOR BLVD STE 103
ST LOUIS PARK MN
55416-2735
US

V. Phone/Fax

Practice location:
  • Phone: 763-614-0363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2068
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: