Provider Demographics
NPI:1508349234
Name:NORTHSTAR REGIONAL
Entity Type:Organization
Organization Name:NORTHSTAR REGIONAL
Other - Org Name:NORTHSTAR REGIONAL CLINICAL LABORATORY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-856-3932
Mailing Address - Street 1:1045 STOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2149
Mailing Address - Country:US
Mailing Address - Phone:952-448-6557
Mailing Address - Fax:952-448-6047
Practice Address - Street 1:1045 STOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2149
Practice Address - Country:US
Practice Address - Phone:952-448-6557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHSTAR REGIONAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-10
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory