Provider Demographics
NPI:1447857230
Name:MINNEAPOLIS INTEGRATIVE MEDICINE CENTER, LLC
Entity type:Organization
Organization Name:MINNEAPOLIS INTEGRATIVE MEDICINE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:952-222-7670
Mailing Address - Street 1:1120 WAYZATA BLVD E STE 110
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1984
Mailing Address - Country:US
Mailing Address - Phone:952-222-7670
Mailing Address - Fax:763-210-6809
Practice Address - Street 1:1120 WAYZATA BLVD E STE 110
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1984
Practice Address - Country:US
Practice Address - Phone:952-222-7670
Practice Address - Fax:763-210-6809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-05
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty