Healthcare Provider Details

I. General information

NPI: 1497020002
Provider Name (Legal Business Name): CORY BLAUVELT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 AMERICAN BLVD W STE 945
BLOOMINGTON MN
55437-1162
US

IV. Provider business mailing address

5001 AMERICAN BLVD W STE 945
BLOOMINGTON MN
55437-1162
US

V. Phone/Fax

Practice location:
  • Phone: 952-835-6653
  • Fax: 952-835-3895
Mailing address:
  • Phone: 952-835-6653
  • Fax: 952-835-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: