Provider Demographics
NPI:1174975528
Name:PARK NICOLLET
Entity type:Organization
Organization Name:PARK NICOLLET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR PARK NICOLLET MGRC
Authorized Official - Prefix:
Authorized Official - First Name:BERNT
Authorized Official - Middle Name:
Authorized Official - Last Name:HELGAAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-993-1440
Mailing Address - Street 1:7102 OLIVE LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3573
Mailing Address - Country:US
Mailing Address - Phone:763-494-4686
Mailing Address - Fax:
Practice Address - Street 1:9555 UPLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4485
Practice Address - Country:US
Practice Address - Phone:952-993-1440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center