Healthcare Provider Details

I. General information

NPI: 1275632234
Provider Name (Legal Business Name): JACK VICTOR LUNDBOHM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 2ND ST NW STE A
ROSEAU MN
56751
US

IV. Provider business mailing address

317 2ND ST NW STE A
ROSEAU MN
56751
US

V. Phone/Fax

Practice location:
  • Phone: 218-463-2992
  • Fax: 218-463-1229
Mailing address:
  • Phone: 218-463-2992
  • Fax: 218-463-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1792
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: