Healthcare Provider Details

I. General information

NPI: 1962780932
Provider Name (Legal Business Name): BROADENED HORIZONS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9025 BURTON CT NW OFFICE SUITE
RICE MN
56367-6602
US

IV. Provider business mailing address

9025 BURTON CT NW OFFICE SUITE
RICE MN
56367-6602
US

V. Phone/Fax

Practice location:
  • Phone: 612-851-1040
  • Fax: 866-672-8919
Mailing address:
  • Phone: 612-851-1040
  • Fax: 866-672-8919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. MARK EARL FELLING
Title or Position: PRESIDENT
Credential: EE, MBA
Phone: 612-851-1040