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General NPI Number Information
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NPI Number | 1164089447
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Entity Type | Organization
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Legal Business Name | SAGE PRAIRIE LABORATORY
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Dates
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Enumeration Date | 05/22/2019
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Last Update Date | 05/22/2019
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Provider Practice Location Address
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Address Line | 1440 DUCKWOOD DR
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City | EAGAN
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State | MN
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Zip | 55122-1451
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Country | US
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Telephone | 651-238-5558
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Fax | 612-437-4992
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Provider Business Mailing Address
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Address Line | 1440 DUCKWOOD DR STE 100
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City | EAGAN
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State | MN
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Zip | 55122-1451
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Country | US
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Telephone | 651-238-5558
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Fax | 612-437-4992
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | GRANT ARNOLD PYLKAS
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Credential | MMA
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Telephone | 651-238-5558
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246Z00000X
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Taxonomy Name | Other Specialist/Technologist
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License Number |
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License Number State |
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