Healthcare Provider Details

I. General information

NPI: 1992126429
Provider Name (Legal Business Name): ASSET CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2013
Last Update Date: 12/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 MINNESOTA ST SUITE W1260
SAINT PAUL MN
55101-1314
US

IV. Provider business mailing address

332 MINNESOTA ST SUITE W1260
SAINT PAUL MN
55101-1314
US

V. Phone/Fax

Practice location:
  • Phone: 651-341-7688
  • Fax: 866-307-8760
Mailing address:
  • Phone: 651-341-7688
  • Fax: 866-307-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number1861
License Number StateMN

VIII. Authorized Official

Name: DR. MARK L WILLENBRING
Title or Position: PRESIDENT
Credential: M.D.
Phone: 651-348-7611