Provider Demographics
NPI:1447093927
Name:MILLE LACS ISANTI & SHERBURNE COS
Entity type:Organization
Organization Name:MILLE LACS ISANTI & SHERBURNE COS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LSN
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WYGANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-419-0211
Mailing Address - Street 1:706 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-1502
Mailing Address - Country:US
Mailing Address - Phone:763-389-6195
Mailing Address - Fax:
Practice Address - Street 1:706 1ST ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1502
Practice Address - Country:US
Practice Address - Phone:763-389-6195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-13
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local