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General NPI Number Information
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NPI Number | 1073976601
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Entity Type | Organization
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Legal Business Name | SHAKOPEE PAIN CLINIC
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Dates
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Enumeration Date | 03/31/2016
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Last Update Date | 03/31/2016
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Provider Practice Location Address
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Address Line | 255 1ST AVE E
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City | SHAKOPEE
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State | MN
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Zip | 55379-1440
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Country | US
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Telephone | 952-777-2990
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Fax |
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Provider Business Mailing Address
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Address Line | 255 1ST AVE E
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City | SHAKOPEE
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State | MN
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Zip | 55379-1440
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Country | US
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Telephone | 952-777-2990
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. ANTONIO BARRIENTEZ
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Credential |
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Telephone | 952-777-2990
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 866867100036
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License Number State | MN
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