Provider Demographics
NPI:1376713818
Name:AUGUSTINE, DANIEL (CAPS)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:AUGUSTINE
Suffix:
Gender:M
Credentials:CAPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 W 22ND ST
Mailing Address - Street 2:LL
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-3202
Mailing Address - Country:US
Mailing Address - Phone:612-724-1911
Mailing Address - Fax:612-724-1851
Practice Address - Street 1:509 W 22ND ST
Practice Address - Street 2:LL
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-3202
Practice Address - Country:US
Practice Address - Phone:612-724-1911
Practice Address - Fax:612-724-1851
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20065360171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN171562OtherU CARE MN
MN715314700Medicaid