Facts
- Status
- A
- Credential
- NP-C
- Type
- Individual
- Enumeration date
- 2016-04-18
- Last updated
- 2016-06-08
Licenses
- License MN
- 201634-8
- License MN
- 201634-8
Location
- Practice location
- 525 MAIN ST W
- City
- MELROSE MN
- Postal code
- 563521043
- Phone
- 320-256-4228
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.