Provider Demographics
NPI:1821646985
Name:MINOR MEDICAL SQUAD PLLC
Entity Type:Organization
Organization Name:MINOR MEDICAL SQUAD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:VITO
Authorized Official - Last Name:DIMUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:612-805-8676
Mailing Address - Street 1:826 TRENTON LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-4496
Mailing Address - Country:US
Mailing Address - Phone:612-805-8676
Mailing Address - Fax:
Practice Address - Street 1:5775 WAYZATA BLVD STE 700
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1233
Practice Address - Country:US
Practice Address - Phone:612-504-6160
Practice Address - Fax:855-818-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health