MEDICARE: TWILIGHT TATTOO

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	246ZA2600X	Medical Art Specialist/Technologist

General Provider Information

NPI Number	:	1295191708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWILIGHT TATTOO

Provider Business Mailing Address
First Line	:	3054 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1716
Country	:	US
Telephone Number	:	612-722-2233
Fax Number	:

Provider Business Practice Location Address
First Line	:	3054 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1716
Country	:	US
Telephone Number	:	612-722-2233
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TONI LOUSIE WALLIN
Credential	:
Telephone Number	:	612-214-1311

Provider Enumeration Date	:	01/13/2016
Last Update Date	:	01/13/2016

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Directions to “TWILIGHT TATTOO ” Practice Location

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