Healthcare Provider Details

I. General information

NPI: 1346550555
Provider Name (Legal Business Name): APPLE VALLEY MEDICAL CLINIC, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15100 GALAXIE AVE
APPLE VALLEY MN
55124
US

IV. Provider business mailing address

14655 GALAXIE AVE
APPLE VALLEY MN
55124
US

V. Phone/Fax

Practice location:
  • Phone: 952-432-6161
  • Fax: 952-891-3921
Mailing address:
  • Phone: 952-432-6161
  • Fax: 952-891-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number723
License Number StateMN

VIII. Authorized Official

Name: MARK POTTENGER
Title or Position: ADMINISTRATOR
Credential:
Phone: 952-953-9285