Basic Information
| Provider Information | |||||||||
| NPI: | 1740476043 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESJARLAIS | ||||||||
| FirstName: | VERNON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27885 170TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | CROOKSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567169444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182813506 | ||||||||
| FaxNumber: | 2182813015 | ||||||||
| Practice Location | |||||||||
| Address1: | 27885 170TH AVE SW | ||||||||
| Address2: | |||||||||
| City: | CROOKSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567169444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182813506 | ||||||||
| FaxNumber: | 2182813015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2007 | ||||||||
| LastUpdateDate: | 09/20/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3747P1801X | Y | Nursing Service Related Providers | Technician | Personal Care Attendant |
No ID Information.