Provider Demographics
NPI:1417554155
Name:CENTER FOR RESTORATIVE SURGERY AT MAPLE GROVE, LLC
Entity Type:Organization
Organization Name:CENTER FOR RESTORATIVE SURGERY AT MAPLE GROVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-432-7655
Mailing Address - Street 1:13601 80TH CIR N STE 100
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-8906
Mailing Address - Country:US
Mailing Address - Phone:763-432-7655
Mailing Address - Fax:763-432-7501
Practice Address - Street 1:13601 80TH CIR N STE 100
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-8906
Practice Address - Country:US
Practice Address - Phone:763-432-7655
Practice Address - Fax:763-432-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical