Healthcare Provider Details

I. General information

NPI: 1053134502
Provider Name (Legal Business Name): BRIANNA GRACE SEILER LUCAS I CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 BECKER AVE SW
WILLMAR MN
56201-3302
US

IV. Provider business mailing address

404 16TH AVE SW APT 301
WILLMAR MN
56201-4146
US

V. Phone/Fax

Practice location:
  • Phone: 320-231-4250
  • Fax: 320-231-4850
Mailing address:
  • Phone: 320-212-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number747567
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: