Healthcare Provider Details

I. General information

NPI: 1275227605
Provider Name (Legal Business Name): KIMBERLY MARIAN RIESBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 25TH AVE S STE 110
SAINT CLOUD MN
56301-4820
US

IV. Provider business mailing address

600 25TH AVE S STE 110
SAINT CLOUD MN
56301-4820
US

V. Phone/Fax

Practice location:
  • Phone: 320-250-6674
  • Fax:
Mailing address:
  • Phone: 320-250-6674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: