Provider Demographics
NPI:1801315650
Name:NORTH STAR PODIATRIC LABORATORIES INC.
Entity type:Organization
Organization Name:NORTH STAR PODIATRIC LABORATORIES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDORTHIST
Authorized Official - Phone:651-426-9388
Mailing Address - Street 1:13419 FENWAY BLVD N STE 101
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-7466
Mailing Address - Country:US
Mailing Address - Phone:651-426-9388
Mailing Address - Fax:651-426-7450
Practice Address - Street 1:7400 LYNDALE AVE S STE 160
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4142
Practice Address - Country:US
Practice Address - Phone:651-353-5845
Practice Address - Fax:612-224-9457
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:1962409995
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-13
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment