Provider Demographics
NPI:1801842729
Name:HEALTHEAST MEDICAL RESEARCH INSTITUTE
Entity Type:Organization
Organization Name:HEALTHEAST MEDICAL RESEARCH INSTITUTE
Other - Org Name:HEALTHEAST COTTAGE GROVE 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 1:6936 PINE ARBOR DRIVE SOUTH
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-3007
Mailing Address - Country:US
Mailing Address - Phone:651-326-5800
Mailing Address - Fax:651-326-5802
Practice Address - Street 1:6936 PINE ARBOR DRIVE SOUTH
Practice Address - Street 2:SUITE 100
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-3007
Practice Address - Country:US
Practice Address - Phone:651-326-5800
Practice Address - Fax:651-326-5802
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHEAST MEDICAL RESEARCH INSTITUTE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-25
Last Update Date:2015-05-20
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
MN0841630008OtherMEDICARE PTAN
MN543525100Medicaid
MN0841630008OtherMEDICARE PTAN