Provider Demographics
NPI:1063439032
Name:KNIGHTON CLINIC FOR REPARATIVE MED., P.A
Entity type:Organization
Organization Name:KNIGHTON CLINIC FOR REPARATIVE MED., P.A
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:REED
Authorized Official - Last Name:KNIGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-920-2009
Mailing Address - Street 1:2460 HIGHWAY 100 S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1704
Mailing Address - Country:US
Mailing Address - Phone:952-920-2009
Mailing Address - Fax:
Practice Address - Street 1:2460 HIGHWAY 100 S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1704
Practice Address - Country:US
Practice Address - Phone:952-920-2009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN290762086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC01681Medicare PIN