Healthcare Provider Details

I. General information

NPI: 1982965505
Provider Name (Legal Business Name): FSMINNESOTAONE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7060 VALLEY CREEK PLZ SUITE 113
WOODBURY MN
55125-2269
US

IV. Provider business mailing address

7060 VALLEY CREEK PLZ SUITE 113
WOODBURY MN
55125-2269
US

V. Phone/Fax

Practice location:
  • Phone: 651-739-3668
  • Fax: 651-739-3678
Mailing address:
  • Phone: 651-739-3668
  • Fax: 651-739-3678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number39232252
License Number StateMN

VIII. Authorized Official

Name: MR. TED LOWE
Title or Position: CERTIFIED PEDORTHIST
Credential: C.PED
Phone: 651-739-3668