Healthcare Provider Details

I. General information

NPI: 1316313562
Provider Name (Legal Business Name): MR. BLAISE AUGUSTE BINDOULA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49725 COUNTY 83
STAPLES MN
56479-5280
US

IV. Provider business mailing address

49725 COUNTY 83
STAPLES MN
56479-5280
US

V. Phone/Fax

Practice location:
  • Phone: 218-894-1515
  • Fax: 218-894-8767
Mailing address:
  • Phone: 218-894-8423
  • Fax: 218-894-8943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberR191271-5
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberCNP5148
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCNP5148
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP5148
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: