Provider Demographics
NPI:1114438546
Name:PARK NICOLLET HEALTH CARE PRODUCTS
Entity Type:Organization
Organization Name:PARK NICOLLET HEALTH CARE PRODUCTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:BREY
Authorized Official - Suffix:
Authorized Official - Credentials:DELEGATED OFFICIAL
Authorized Official - Phone:952-993-6832
Mailing Address - Street 1:3800 PARK NICOLLET BLVD
Mailing Address - Street 2:6WS01C
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416
Mailing Address - Country:US
Mailing Address - Phone:952-993-6832
Mailing Address - Fax:
Practice Address - Street 1:411 STAGELINE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7848
Practice Address - Country:US
Practice Address - Phone:715-531-6400
Practice Address - Fax:952-993-0562
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK NICOLLET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6019472332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies