Healthcare Provider Details

I. General information

NPI: 1306767918
Provider Name (Legal Business Name): KEVIN WAHLBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55123 W GRINDSTONE RD
SANDSTONE MN
55072-2692
US

IV. Provider business mailing address

55123 W GRINDSTONE RD
SANDSTONE MN
55072-2692
US

V. Phone/Fax

Practice location:
  • Phone: 320-385-4477
  • Fax: 320-216-7638
Mailing address:
  • Phone: 320-385-4477
  • Fax: 320-216-7638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberY275218560914
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: