| NPI | 1699054213 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JESSIN SKOUG Owner 651-565-4863 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305S00000X Point of Service (Licence: MN 5533) |
| Additional Taxonomies | 305R00000X Preferred Provider Organization (Licence: WI 4754-012) |
| Enumeration Date | 2011-08-12 |
| Last Update Date | 2011-08-12 |