Healthcare Provider Details

I. General information

NPI: 1003216425
Provider Name (Legal Business Name): ZUDAC ENTERPRISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 09/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 HIGHWAY 96 E 204C
WHITE BEAR LAKE MN
55110-3624
US

IV. Provider business mailing address

927 RIDERS CLUB RD
ONALASKA WI
54650-2041
US

V. Phone/Fax

Practice location:
  • Phone: 651-429-6072
  • Fax:
Mailing address:
  • Phone: 608-783-7399
  • Fax: 608-783-7398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1404
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2742
License Number StateMN

VIII. Authorized Official

Name: ROBERT JAMES BREAULT
Title or Position: HEARING INSTRUMENT DISPENSER
Credential:
Phone: 651-354-5906