Provider Demographics
NPI:1669739694
Name:INTREPID OF EDINA, INC.
Entity type:Organization
Organization Name:INTREPID OF EDINA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNYSZ
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:14841 DALLAS PKWY STE 625
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7641
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3900
Practice Address - Street 1:3433 BROADWAY ST NE STE 240B
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-1740
Practice Address - Country:US
Practice Address - Phone:651-633-6404
Practice Address - Fax:651-633-6729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
241596Medicare Oscar/Certification