=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356841019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOOD CREST BUILDING & REMODELING INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2018
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24140 PRIMROSE LN N
-----------------------------------------------------
City | SCANDIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55073-9681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-433-3779
-----------------------------------------------------
Fax | 651-433-3771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24140 PRIMROSE LN N
-----------------------------------------------------
City | SCANDIA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55073-9681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-433-3779
-----------------------------------------------------
Fax | 651-433-3771
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUILDING CONTRACTOR
-----------------------------------------------------
Name | ERIK JAMES ANDERSON
-----------------------------------------------------
Credential | CEO
-----------------------------------------------------
Telephone | 651-246-9457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171WH0202X
-----------------------------------------------------
Taxonomy Name | Home Modifications Contractor
-----------------------------------------------------
License Number | BC628706
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------