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General NPI Number Information
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NPI Number | 1154402600
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Entity Type | Organization
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Legal Business Name | HEIDE'S MASTECTOMY SERVICES, INC.
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 05/07/2018
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Provider Practice Location Address
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Address Line | 3400 W 66TH ST SUITE 440
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City | EDINA
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State | MN
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Zip | 55435-2111
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Country | US
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Telephone | 952-925-7837
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Fax | 952-925-1081
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Provider Business Mailing Address
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Address Line | 3400 W 66TH ST STE 245
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City | EDINA
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State | MN
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Zip | 55435-2170
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Country | US
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Telephone | 952-925-7837
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Fax | 952-925-1081
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Authorized Official
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Title or Position | OWNER
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Name | MS. KATHLEEN RUTH HEIDE-WRAZIDLO
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Credential | CFM CFC
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Telephone | 952-925-7837
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | N/A
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License Number State | MN
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