Provider Demographics
NPI:1295717874
Name:INTREPID AFFILIATES INC
Entity type:Organization
Organization Name:INTREPID AFFILIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:VONARX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-285-7300
Mailing Address - Street 1:6600 FRANCE AVENUE SOUTH
Mailing Address - Street 2:SUITE 510
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1804
Mailing Address - Country:US
Mailing Address - Phone:952-285-7300
Mailing Address - Fax:952-285-6827
Practice Address - Street 1:5445 SOUTH WYCK BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614
Practice Address - Country:US
Practice Address - Phone:419-861-2722
Practice Address - Fax:419-861-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0459614Medicaid