Healthcare Provider Details

I. General information

NPI: 1104850155
Provider Name (Legal Business Name): MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W STE 189S
ST PAUL MN
55114
US

IV. Provider business mailing address

3475 PLYMOUTH BLVD STE 200
PLYMOUTH MN
55447-1539
US

V. Phone/Fax

Practice location:
  • Phone: 651-332-7474
  • Fax: 651-332-7475
Mailing address:
  • Phone: 763-577-2484
  • Fax: 763-577-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

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