=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154132215
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK LEIKNES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2025
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5640 W BROADWAY AVE STE B
-----------------------------------------------------
City | CRYSTAL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55428-3567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-836-5421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 972 REDWELL LN
-----------------------------------------------------
City | APPLE VALLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55124-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 2957
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------