Provider Demographics
NPI:1891891438
Name:CELLERATION INC
Entity Type:Organization
Organization Name:CELLERATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-224-8700
Mailing Address - Street 1:6321 BURY DRIVE SUITE 15
Mailing Address - Street 2:CELLERATION, INC
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55346
Mailing Address - Country:US
Mailing Address - Phone:952-224-8700
Mailing Address - Fax:952-224-8750
Practice Address - Street 1:6321 BURY DRIVE SUITE 15
Practice Address - Street 2:CELLERATION, INC
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55346
Practice Address - Country:US
Practice Address - Phone:952-224-8700
Practice Address - Fax:952-224-8750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4865891332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid