MEDICARE: DOMINIC CARDELLI JR.

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	171M00000X	Case Manager/Care Coordinator		MN

General Provider Information

NPI Number	:	1558295774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIC CARDELLI JR.

Provider Business Mailing Address
First Line	:	10293 209TH ST W
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-9735
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10293 209TH ST W
Second Line	:
City	:	LAKEVILLE
State	:	MN
Zip	:	55044-9735
Country	:	US
Telephone Number	:	612-545-8366
Fax Number	:

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

Provider Enumeration Date	:	06/11/2026
Last Update Date	:	06/11/2026

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