Provider Demographics
NPI:1023414281
Name:INTREPID USA
Entity type:Organization
Organization Name:INTREPID USA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-513-5400
Mailing Address - Street 1:5775 WAYZATA BLVD STE 540
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1230
Mailing Address - Country:US
Mailing Address - Phone:952-513-5400
Mailing Address - Fax:952-513-5444
Practice Address - Street 1:5775 WAYZATA BLVD STE 540
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1230
Practice Address - Country:US
Practice Address - Phone:952-513-5400
Practice Address - Fax:952-513-5444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTREPID USA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN326853251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN247154Medicare PIN