=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336310283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHEAST CARE SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2008
-----------------------------------------------------
Last Update Date | 10/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1690 UNIVERSITY AVE W SUITE 570
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-3723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-232-4800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5626 OBERLIN DR SUITE 110
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-625-2990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | KENNY HEINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-625-2990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | PY32377
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------