Individual
LAO PHA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
171 LAKE ST N # 102, BIG LAKE, MN 55309-9254
(651) 774-1166
Mailing address
171 LAKE ST N # 102, BIG LAKE, MN 55309-9254
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
374889
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
A304195200
—
MN
Enumeration date
08/14/2014
Last updated
08/14/2014
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