=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205956125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREVENTIVE CARDIOLOGY INSTITUTE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6545 FRANCE AVE S SUITE 290
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-924-1550
-----------------------------------------------------
Fax | 952-924-1527
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6545 FRANCE AVE S SUITE 290
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55435-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-924-1550
-----------------------------------------------------
Fax | 952-924-1527
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC DIRECTOR
-----------------------------------------------------
Name | DR. JAMES H. ZAVORAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 952-924-1550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 17427
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------