| NPI | 1558064865 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLY FOX Director 763-229-7105 |
| Organization Subpart ? | No |
| Primary Taxonomy | 251S00000X |
| Additional Taxonomies | 305S00000X Point of Service |
| Enumeration Date | 2023-03-24 |
| Last Update Date | 2023-06-07 |