Healthcare Provider Details

I. General information

NPI: 1700595741
Provider Name (Legal Business Name): MS. KACIE MARIE BJERK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2022
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 UNIVERSITY AVE
CROOKSTON MN
56716-5000
US

IV. Provider business mailing address

310 7TH ST SW
ROSEAU MN
56751-1478
US

V. Phone/Fax

Practice location:
  • Phone: 218-281-8427
  • Fax:
Mailing address:
  • Phone: 218-469-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3725
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: