Healthcare Provider Details

I. General information

NPI: 1174268478
Provider Name (Legal Business Name): RIVER BLUFFS HEALTH AND WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 04/30/2023
Certification Date: 04/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N CHESTNUT ST STE 108
LA CRESCENT MN
55947-1282
US

IV. Provider business mailing address

205 N CHESTNUT ST STE 108
LA CRESCENT MN
55947-1282
US

V. Phone/Fax

Practice location:
  • Phone: 507-323-1200
  • Fax: 507-323-1203
Mailing address:
  • Phone: 507-323-1200
  • Fax: 507-323-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. DEREK J DULEK
Title or Position: MANAGING MEMBER
Credential: MLS(ASCP)CM
Phone: 507-323-1200