| Minor Medical Squad Pllc | |
|
5775 Wayzata Blvd Ste 700 St Louis Park MN 55416-1233 | |
| (612) 504-6160 | |
| (855) 818-2050 |
| Full Name | Minor Medical Squad Pllc |
|---|---|
| Speciality | Clinic/Center |
| Location | 5775 Wayzata Blvd Ste 700, St Louis Park, Minnesota |
| Authorized Official Name and Position | Michael Vito Dimucci (OWNER, FAMILY NURSE PRACTITIONER) |
| Authorized Official Contact | 6128058676 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Minor Medical Squad Pllc 826 Trenton Ln N Plymouth MN 55441-4496 Ph: (612) 805-8676 | Minor Medical Squad Pllc 5775 Wayzata Blvd Ste 700 St Louis Park MN 55416-1233 Ph: (612) 504-6160 |
| NPI Number | 1821646985 |
|---|---|
| Provider Enumeration Date | 08/30/2019 |
| Last Update Date | 09/30/2022 |
| Medicare PECOS PAC ID | 4284063975 |
|---|---|
| Medicare Enrollment ID | O20200331003589 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1821646985 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QC1500X | Clinic/center - Community Health | (* (Not Available)) | Secondary |
| Provider Name | Michael Vito Dimucci |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1083694806 PECOS PAC ID: 1759286842 Enrollment ID: I20031203000064 |
| Provider Name | Kumba U Kanu |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194021766 PECOS PAC ID: 4486945169 Enrollment ID: I20160628001210 |
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