Provax LLC

Primary specialty

Community Health Clinic/CenterTaxonomy code 261QC1500X

License

R106374-5 Issued in MN

Legal business name

PROVAX LLC

Practice address

2018 Stone Creek Dr
Chanhassen, MN 55317-7410

Phone

(952) 470-6005

NPI assigned

Oct 5, 2009

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Cindy L Egelston, R.N.

Title

Owner

Phone

(952) 470-6005

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1254700800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1254700800000",
    "number": "1619202934",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2018 STONE CREEK DR",
            "city": "CHANHASSEN",
            "state": "MN",
            "postal_code": "553177410",
            "telephone_number": "952-470-6005"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2018 STONE CREEK DR",
            "city": "CHANHASSEN",
            "state": "MN",
            "postal_code": "553177410",
            "telephone_number": "952-470-6005"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVAX LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-10-05",
        "last_updated": "2009-10-05",
        "status": "A",
        "authorized_official_last_name": "EGELSTON",
        "authorized_official_first_name": "CINDY",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "952-470-6005",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "R.N."
    },
    "taxonomies": [
        {
            "code": "261QC1500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Community Health",
            "state": "MN",
            "license": "R106374-5",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• James Ernest Peck, PH.
• Katherine B Perusse, DO
• Jenelle Peterson
• PHS/Chanhassen,Inc.
• Katherine Stratton Posch, PSYD, LP
• Kathryn Puklich, DPT, PT
• Gail N Raether, D.D.S.
• Carmen Real, DDS
• Patrice Reed-Zweber, MA, LPCC, LADC
• Natasha-Kristin Reilly

• Community Health Clinic/Center in Chanhassen, MN
• Providers in Chanhassen, MN by specialty
• Community Health Clinic/Center in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 5, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.