=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083872527
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KOTA CONNECTIONS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2008
-----------------------------------------------------
Last Update Date | 05/31/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8500 210TH ST W SUITE 148
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-5707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-469-1555
-----------------------------------------------------
Fax | 952-469-1478
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8500 210TH ST W SUITE 148
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-5707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-469-1555
-----------------------------------------------------
Fax | 952-469-1478
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | MR. DAVID J. MODRYNSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-469-1555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 1009867-1-WS
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------