| NPI | 1518362193 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MEGAN OUDEKERK Owner 651-688-0488 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: MN 1852) |
| Enumeration Date | 2014-10-25 |
| Last Update Date | 2024-04-01 |