Provider Demographics
NPI:1558602607
Name:MINNESOTA MEDICAL IMAGING, LLC
Entity Type:Organization
Organization Name:MINNESOTA MEDICAL IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER - HSI
Authorized Official - Prefix:MISS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-964-1810
Mailing Address - Street 1:715 FLORIDA AVE S
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55426-1719
Mailing Address - Country:US
Mailing Address - Phone:612-354-7905
Mailing Address - Fax:612-315-4165
Practice Address - Street 1:715 FLORIDA AVE S
Practice Address - Street 2:SUITE 205
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1719
Practice Address - Country:US
Practice Address - Phone:612-354-7905
Practice Address - Fax:612-315-4165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2014-10-08
Deactivation Date:2014-09-26
Deactivation Code:
Reactivation Date:2014-10-08
Provider Licenses
StateLicense IDTaxonomies
MN261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1801130158OtherNPI