=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184951386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SYNERGY HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2009
-----------------------------------------------------
Last Update Date | 10/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4820 WEST 77TH STREET SUITE 145
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-4822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-920-9830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4820 WEST 77TH STREET SUITE 145
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-4822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-920-9830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RUTH EATON
-----------------------------------------------------
Credential | RN, LAC
-----------------------------------------------------
Telephone | 952-920-9830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 1297
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------