Healthcare Provider Details

I. General information

NPI: 1386374593
Provider Name (Legal Business Name): PRIMARY ENT, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14020 HWY 13 S STE 350
SAVAGE MN
55378-7103
US

IV. Provider business mailing address

6021 NORTHWOOD RDG
BLOOMINGTON MN
55438-1282
US

V. Phone/Fax

Practice location:
  • Phone: 952-395-2500
  • Fax: 952-395-2501
Mailing address:
  • Phone: 612-406-9966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN LUTHER BOONE
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 612-406-9966