Healthcare Provider Details

I. General information

NPI: 1093397796
Provider Name (Legal Business Name): HULTMAN LAKE ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 MAIN ST S
PINE CITY MN
55063-1660
US

IV. Provider business mailing address

805 MAIN ST S
PINE CITY MN
55063-1660
US

V. Phone/Fax

Practice location:
  • Phone: 320-629-5288
  • Fax:
Mailing address:
  • Phone: 320-629-5288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOEL BLOMBERG
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: D.C.
Phone: 320-629-5288