Provider Demographics
NPI:1922182120
Name:MIDWEST STONE MANAGEMENT
Entity Type:Organization
Organization Name:MIDWEST STONE MANAGEMENT
Other - Org Name:MIDWEST STONE
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NYSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-633-9414
Mailing Address - Street 1:1885 COUNTY ROAD C W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1304
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1885 COUNTY ROAD C W
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-1304
Practice Address - Country:US
Practice Address - Phone:651-633-9414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy