Healthcare Provider Details

I. General information

NPI: 1144071879
Provider Name (Legal Business Name): SAMUEL BORNHORST OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 66TH ST STE 240
EDINA MN
55435-2100
US

IV. Provider business mailing address

3500 AMERICAN BLVD W STE 300
BLOOMINGTON MN
55431-4442
US

V. Phone/Fax

Practice location:
  • Phone: 952-857-0304
  • Fax:
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number102766
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: