Healthcare Provider Details

I. General information

NPI: 1386551588
Provider Name (Legal Business Name): GLEN THOMAS BELLEFEUILLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1984 260TH AVE LOT H10
MORA MN
55051-6558
US

IV. Provider business mailing address

1984 260TH AVE LOT H10
MORA MN
55051-6558
US

V. Phone/Fax

Practice location:
  • Phone: 320-385-4477
  • Fax: 320-216-7638
Mailing address:
  • Phone: 320-385-4477
  • Fax: 320-216-7638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberT740255698111
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: