Healthcare Provider Details

I. General information

NPI: 1124775077
Provider Name (Legal Business Name): BENJAMIN KOTHE LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 CLIFTON AVE STE C101
MINNEAPOLIS MN
55403-3235
US

IV. Provider business mailing address

10681 SMETANA RD APT 106
MINNETONKA MN
55343-8083
US

V. Phone/Fax

Practice location:
  • Phone: 651-335-6534
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1992
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: