Healthcare Provider Details

I. General information

NPI: 1346645348
Provider Name (Legal Business Name): TOM BOMBERG D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 WINNETKA AVE N STE 100
NEW HOPE MN
55427-2091
US

IV. Provider business mailing address

3410 WINNETKA AVE N STE 100
NEW HOPE MN
55427-2091
US

V. Phone/Fax

Practice location:
  • Phone: 763-450-1755
  • Fax: 763-496-1657
Mailing address:
  • Phone: 763-450-1755
  • Fax: 763-496-1657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08002780A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.012670
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6170
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: