Healthcare Provider Details

I. General information

NPI: 1669181558
Provider Name (Legal Business Name): KIMBERLY LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19772 160TH ST N
BORUP MN
56519-9660
US

IV. Provider business mailing address

19772 160TH ST N
BORUP MN
56519-9660
US

V. Phone/Fax

Practice location:
  • Phone: 701-541-7220
  • Fax:
Mailing address:
  • Phone: 701-541-7220
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number1112157
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: