=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063585529
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTLOOK HEALTH SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6413 OAK ST
-----------------------------------------------------
City | NORTH BRANCH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55056-5129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-674-4570
-----------------------------------------------------
Fax | 651-674-8740
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 320
-----------------------------------------------------
City | NORTH BRANCH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55056-0320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-674-4570
-----------------------------------------------------
Fax | 651-674-8740
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | BETTY NELSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 651-674-4570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------