Provider Demographics
NPI:1164089447
Name:SAGE PRAIRIE LABORATORY
Entity Type:Organization
Organization Name:SAGE PRAIRIE LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:ARNOLD
Authorized Official - Last Name:PYLKAS
Authorized Official - Suffix:
Authorized Official - Credentials:MMA
Authorized Official - Phone:651-238-5558
Mailing Address - Street 1:1440 DUCKWOOD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-1451
Mailing Address - Country:US
Mailing Address - Phone:651-238-5558
Mailing Address - Fax:612-437-4992
Practice Address - Street 1:1440 DUCKWOOD DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-1451
Practice Address - Country:US
Practice Address - Phone:651-238-5558
Practice Address - Fax:612-437-4992
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDICAL ADDICTION TREATMENT CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty