Provider Demographics
NPI:1841688835
Name:THOMAS RUSSELL BRAATEN
Entity type:Organization
Organization Name:THOMAS RUSSELL BRAATEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:BRAATEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-780-3843
Mailing Address - Street 1:8840 POLK ST NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434
Mailing Address - Country:US
Mailing Address - Phone:763-780-3843
Mailing Address - Fax:
Practice Address - Street 1:22020 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CEDAR
Practice Address - State:MN
Practice Address - Zip Code:55011
Practice Address - Country:US
Practice Address - Phone:763-780-3843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN468726286374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty