MEDICARE: JOHN RUNDQUIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	300347	MN

General Provider Information

NPI Number	:	1023589082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN RUNDQUIST

Provider Business Mailing Address
First Line	:	2823 WAYZATA BLVD
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2125
Country	:	US
Telephone Number	:	612-374-0506
Fax Number	:	651-323-2051

Provider Business Practice Location Address
First Line	:	7250 METRO BLVD STE 100
Second Line	:
City	:	EDINA
State	:	MN
Zip	:	55439-2145
Country	:	US
Telephone Number	:	612-374-0506
Fax Number	:	651-323-2051

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	03/29/2021

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