Provider Demographics
NPI:1003316852
Name:MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Entity Type:Organization
Organization Name:MINNESOTA HEAD AND NECK PAIN CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING DEPART TEAM LEAD
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-332-7476
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 189S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2001
Mailing Address - Country:US
Mailing Address - Phone:651-332-7476
Mailing Address - Fax:651-332-7475
Practice Address - Street 1:622 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-6153
Practice Address - Country:US
Practice Address - Phone:763-577-2484
Practice Address - Fax:763-577-1375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty