Healthcare Provider Details

I. General information

NPI: 1790787216
Provider Name (Legal Business Name): LAND OF LAKES ORTHOTICS & PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14395 23RD AVE N
PLYMOUTH MN
55447-4704
US

IV. Provider business mailing address

14395 23RD AVE N
PLYMOUTH MN
55447-4704
US

V. Phone/Fax

Practice location:
  • Phone: 952-745-3004
  • Fax: 952-745-3010
Mailing address:
  • Phone: 952-745-3004
  • Fax: 952-745-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. CLARK V POULSON
Title or Position: PROSTHETIST ORTHOTIST
Credential: CPO
Phone: 952-745-3004