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General NPI Number Information
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NPI Number | 1144749862
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Entity Type | Organization
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Legal Business Name | PARK NICOLLET HEALTH CARE PRODUCTS
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Dates
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Enumeration Date | 09/13/2017
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Last Update Date | 11/07/2024
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Provider Practice Location Address
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Address Line | 155 RADIO DRIVE
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City | WOODBURY
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State | MN
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Zip | 55125-2040
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Country | US
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Telephone | 952-831-8742
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Fax | 952-993-0562
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Provider Business Mailing Address
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Address Line | 3800 PARK NICOLLET BLVD # MS 61901C
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-2527
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Country | US
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Telephone |
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Fax | 952-993-0562
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Authorized Official
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Title or Position | SUPERVISOR/DELEGATED OFFICIAL
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Name | KRISTIN D BREY
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Credential |
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Telephone | 952-993-6832
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 6019472
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License Number State | MN
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