Provider Demographics
NPI:1730128398
Name:HEALTHEAST MEDICAL RESEARCH INSTITUTE
Entity Type:Organization
Organization Name:HEALTHEAST MEDICAL RESEARCH INSTITUTE
Other - Org Name:HEALTHEAST GRAND AVENUE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-232-2250
Mailing Address - Street 1:870 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3291
Mailing Address - Country:US
Mailing Address - Phone:651-326-5650
Mailing Address - Fax:651-326-5671
Practice Address - Street 1:870 GRAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3291
Practice Address - Country:US
Practice Address - Phone:651-326-5650
Practice Address - Fax:651-326-5671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHEAST MEDICAL RESEARCH INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-06
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0841630019OtherMEDICARE PTAN
MN500719400Medicaid