Healthcare Provider Details

I. General information

NPI: 1649489493
Provider Name (Legal Business Name): WILLOWBRIDGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 ENTERPRISE AVE NE STE 1
ISANTI MN
55040-6814
US

IV. Provider business mailing address

4 ENTERPRISE AVE NE STE 1
ISANTI MN
55040-6814
US

V. Phone/Fax

Practice location:
  • Phone: 763-552-6161
  • Fax: 763-237-3254
Mailing address:
  • Phone: 763-552-6161
  • Fax: 763-237-3254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DIANE ANLAUF
Title or Position: MANAGER
Credential:
Phone: 763-552-6161