Provider Demographics
NPI:1235695594
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 # 6WS01C
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2527
Mailing Address - Country:US
Mailing Address - Phone:952-993-6832
Mailing Address - Fax:952-993-0562
Practice Address - Street 1:8401 GOLDEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4486
Practice Address - Country:US
Practice Address - Phone:952-993-8313
Practice Address - Fax:952-993-0562
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARK NICOLLET
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier