Healthcare Provider Details

I. General information

NPI: 1245791763
Provider Name (Legal Business Name): MIDWEST REGENERATIVE MEDICINE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 N MAIN ST
WARREN MN
56762-1122
US

IV. Provider business mailing address

603 N MAIN ST
WARREN MN
56762-1122
US

V. Phone/Fax

Practice location:
  • Phone: 218-745-6655
  • Fax:
Mailing address:
  • Phone: 218-745-6655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK PEDERSON
Title or Position: OWNER
Credential:
Phone: 218-745-6655