Basic Information
| Provider Information | |||||||||
| NPI: | 1255788162 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NYSTROM & ASSOCIATES, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD NW | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2016 | ||||||||
| LastUpdateDate: | 05/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCALLISTER | ||||||||
| AuthorizedOfficialFirstName: | MARZACK | ||||||||
| AuthorizedOfficialMiddleName: | BALASCO | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 6516289566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LADC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 301604 | MN | Y | Agencies | Case Management |
No ID Information.