Provider Demographics
NPI:1659382075
Name:LIFESCAN MINNESOTA STAND UP MRI
Entity Type:Organization
Organization Name:LIFESCAN MINNESOTA STAND UP MRI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-477-1815
Mailing Address - Street 1:75 VIKING DR W STE 101
Mailing Address - Street 2:
Mailing Address - City:LITTLE CANADA
Mailing Address - State:MN
Mailing Address - Zip Code:55117-1778
Mailing Address - Country:US
Mailing Address - Phone:651-486-7530
Mailing Address - Fax:651-486-7540
Practice Address - Street 1:75 VIKING DR W STE 101
Practice Address - Street 2:
Practice Address - City:LITTLE CANADA
Practice Address - State:MN
Practice Address - Zip Code:55117-1778
Practice Address - Country:US
Practice Address - Phone:651-486-7530
Practice Address - Fax:651-486-7540
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESCAN MINNESOTA STAND UP MRI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN470000067Medicare PIN