Healthcare Provider Details

I. General information

NPI: 1306759048
Provider Name (Legal Business Name): WOODLAKE SPECIALTY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6625 LYNDALE AVE S STE 105
RICHFIELD MN
55423-2673
US

IV. Provider business mailing address

6625 LYNDALE AVE S STE 105
RICHFIELD MN
55423-2673
US

V. Phone/Fax

Practice location:
  • Phone: 612-243-8999
  • Fax:
Mailing address:
  • Phone: 612-243-8999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State

VIII. Authorized Official

Name: BRYAN LEE MOHR
Title or Position: OWNER/CEO
Credential: DPM
Phone: 651-387-0440