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General NPI Number Information
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NPI Number | 1245516178
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Entity Type | Organization
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Legal Business Name | SPECIALIZAED MEDICAL, INC
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Dates
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Enumeration Date | 10/24/2011
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Last Update Date | 10/24/2011
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Provider Practice Location Address
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Address Line | 19679 CALGARY TRL
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City | FARMINGTON
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State | MN
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Zip | 55024-1488
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Country | US
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Telephone | 612-720-3824
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Fax | 888-546-6978
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Provider Business Mailing Address
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Address Line | PO BOX 21715
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City | EAGAN
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State | MN
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Zip | 55121-0715
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Country | US
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Telephone | 612-720-3824
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Fax | 888-546-6978
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Authorized Official
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Title or Position | CEO
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Name | MR. KIRK EDWARD HANSON
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Credential |
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Telephone | 612-720-3824
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335G00000X
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Taxonomy Name | Medical Foods Supplier
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License Number |
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number |
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License Number State | MN
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