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General NPI Number Information
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NPI Number | 1760541700
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Entity Type | Organization
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Legal Business Name | GILLETTE CHILDRENS SPECIALTY HEALTHCARE
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Dates
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Enumeration Date | 12/06/2006
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Last Update Date | 12/13/2019
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Provider Practice Location Address
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Address Line | 435 PHALEN BLVD
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City | SAINT PAUL
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State | MN
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Zip | 55130-5302
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Country | US
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Telephone | 651-636-9443
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Fax |
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Provider Business Mailing Address
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Address Line | 200 UNIVERSITY AVE E
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City | SAINT PAUL
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State | MN
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Zip | 55101-2507
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Country | US
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Telephone | 651-325-2177
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | PATRICK NOLAN
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Credential |
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Telephone | 651-312-3105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State | MN
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