MEDICARE: LAO PHA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	374889	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245639301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAO PHA

Provider Business Mailing Address
First Line	:	171 LAKE ST N # 102
Second Line	:
City	:	BIG LAKE
State	:	MN
Zip	:	55309-9254
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	171 LAKE ST N # 102
Second Line	:
City	:	BIG LAKE
State	:	MN
Zip	:	55309-9254
Country	:	US
Telephone Number	:	651-774-1166
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/14/2014

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Directions to “ LAO PHA ” Practice Location

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