Provider Demographics
NPI:1982679700
Name:MARACON HEALTH CARE SERVICES, INC
Entity Type:Organization
Organization Name:MARACON HEALTH CARE SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ONYEDIMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:NWACHUKU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-641-0895
Mailing Address - Street 1:1595 SELBY AVENUE, SUITE 201
Mailing Address - Street 2:
Mailing Address - City:ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6285
Mailing Address - Country:US
Mailing Address - Phone:651-641-0895
Mailing Address - Fax:651-641-0894
Practice Address - Street 1:1595 SELBY AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6285
Practice Address - Country:US
Practice Address - Phone:651-641-0895
Practice Address - Fax:651-641-0894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN70G05MAOtherBLUE CROSS BLUE SHIELD
4902390001Medicare ID - Type UnspecifiedMEDICARE