Provider Demographics
NPI:1194846782
Name:RANGE PODIATRIC CARE, PA
Entity Type:Organization
Organization Name:RANGE PODIATRIC CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:218-744-1961
Mailing Address - Street 1:2302 HIGHWAY 53
Mailing Address - Street 2:
Mailing Address - City:EVELETH
Mailing Address - State:MN
Mailing Address - Zip Code:55734-8523
Mailing Address - Country:US
Mailing Address - Phone:218-744-1961
Mailing Address - Fax:218-744-1961
Practice Address - Street 1:809 N 6TH AVE
Practice Address - Street 2:NORTHGATE PLAZA
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2308
Practice Address - Country:US
Practice Address - Phone:218-749-3818
Practice Address - Fax:218-749-3874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN774213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN480000590Medicaid
MN480000590Medicaid