Provider Demographics
NPI:1053077024
Name:STEPHENS, TIMOTHY JOHN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22251 169TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-8220
Mailing Address - Country:US
Mailing Address - Phone:612-710-8451
Mailing Address - Fax:
Practice Address - Street 1:22251 169TH ST NW
Practice Address - Street 2:
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-8220
Practice Address - Country:US
Practice Address - Phone:612-710-8451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNBC767187171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications