Healthcare Provider Details

I. General information

NPI: 1780822486
Provider Name (Legal Business Name): JACK V, LUNDBOHM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 2ND ST NW SUITE A
ROSEAU MN
56751-1070
US

IV. Provider business mailing address

317 2ND ST NW SUITE A
ROSEAU MN
56751-1070
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 Code261Q00000X
TaxonomyClinic/Center
License Number1792
License Number StateMN

VIII. Authorized Official

Name: DR. JACK V LUNDBOHM
Title or Position: PRESIDENT
Credential: D.C.
Phone: 218-463-2992