Organization
NW FAMILY PRACTICE ROGERS
Active
Other names
NW FAMILY PRACTICE ROGERS
Organization subpart
No
Provider details
NPI number
Authorized official
DIRENDIA SHACKELFORD (MANAGED CARE SPECIALIST)
(800) 654-0889
Entity
Organization
Contact information
Practice address
21305 JOHN MILLESS DR, ROGERS, MN 55374-9450
(612) 428-2206
(612) 428-2530
Mailing address
21305 JOHN MILLESS DR, ROGERS, MN 55374-9450
Taxonomy
Speciality
Code
Description
License number
State
332900000X
Non-Pharmacy Dispensing Site
Primary
17330
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2423616
OTHER ID NUMBER-COMMERCIAL NUMBER
—
Enumeration date
10/23/2006
Last updated
08/22/2020
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