Basic Information
Provider Information
NPI: 1003002437
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BROWN
FirstName: SALLY
MiddleName: ROSS
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 15449C FOREST BLVD N
Address2:  
City: HUGO
State: MN
PostalCode: 550387329
CountryCode: US
TelephoneNumber: 6514261548
FaxNumber: 6516539444
Practice Location
Address1: 15449C FOREST BLVD N
Address2:  
City: HUGO
State: MN
PostalCode: 550387329
CountryCode: US
TelephoneNumber: 6514261548
FaxNumber: 6516539444
Other Information
ProviderEnumerationDate: 09/19/2007
LastUpdateDate: 09/19/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332B00000X  Y SuppliersDurable Medical Equipment & Medical Supplies 

No ID Information.


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