Healthcare Provider Details

I. General information

NPI: 1811643349
Provider Name (Legal Business Name): SAMUEL R DAHLE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2022
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

IV. Provider business mailing address

2237 WINDSOR LAKE DR
MINNETONKA MN
55305-2635
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone: 952-388-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3426
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: