Healthcare Provider Details

I. General information

NPI: 1730232323
Provider Name (Legal Business Name): BOTTELSON ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 98TH ST
BLOOMINGTON MN
55420-4715
US

IV. Provider business mailing address

601 W 98TH ST
BLOOMINGTON MN
55420-4715
US

V. Phone/Fax

Practice location:
  • Phone: 952-881-2778
  • Fax: 952-881-2821
Mailing address:
  • Phone: 952-881-2778
  • Fax: 952-881-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. RANDALL ANDREW BOTTELSON
Title or Position: OWNER
Credential: BS
Phone: 952-881-2778