MEDICARE: POPULATION HEALTH MANAGEMENT PC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1306518303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POPULATION HEALTH MANAGEMENT PC

Provider Business Mailing Address
First Line	:	4142 SHORELINE DR
Second Line	:
City	:	SPRING PARK
State	:	MN
Zip	:	55384-9629
Country	:	US
Telephone Number	:	866-305-0622
Fax Number	:

Provider Business Practice Location Address
First Line	:	4142 SHORELINE DR
Second Line	:
City	:	SPRING PARK
State	:	MN
Zip	:	55384-9629
Country	:	US
Telephone Number	:	866-305-0622
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DAMON KENTON
Credential	:
Telephone Number	:	612-470-0044

Provider Enumeration Date	:	09/29/2021
Last Update Date	:	09/29/2021

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