Healthcare Provider Details

I. General information

NPI: 1104952639
Provider Name (Legal Business Name): RUTH A BLOMSTER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2443 LARPENTEUR AVE W
LAUDERDALE MN
55113-5234
US

IV. Provider business mailing address

2250 MARION RD
ROSEVILLE MN
55113-3824
US

V. Phone/Fax

Practice location:
  • Phone: 651-917-9800
  • Fax:
Mailing address:
  • Phone: 651-490-1727
  • Fax: 651-636-0735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: