Provider Demographics
NPI:1972107266
Name:SENIOR, WAYNE (CEO)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:SENIOR
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13503 THRUSH ST NW
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-3991
Mailing Address - Country:US
Mailing Address - Phone:763-479-9153
Mailing Address - Fax:
Practice Address - Street 1:13503 THRUSH ST NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3991
Practice Address - Country:US
Practice Address - Phone:763-479-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-26
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1033395488Medicaid