Provider Demographics
NPI:1245791763
Name:MIDWEST REGENERATIVE MEDICINE CENTER PC
Entity Type:Organization
Organization Name:MIDWEST REGENERATIVE MEDICINE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-745-6655
Mailing Address - Street 1:603 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MN
Mailing Address - Zip Code:56762-1122
Mailing Address - Country:US
Mailing Address - Phone:218-745-6655
Mailing Address - Fax:
Practice Address - Street 1:603 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MN
Practice Address - Zip Code:56762-1122
Practice Address - Country:US
Practice Address - Phone:218-745-6655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty