Healthcare Provider Details

I. General information

NPI: 1447985171
Provider Name (Legal Business Name): RIVERTOWN MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5630 MEMORIAL AVE N STE 1
STILLWATER MN
55082-1087
US

IV. Provider business mailing address

5630 MEMORIAL AVE N STE 1
STILLWATER MN
55082-1087
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-2712
  • Fax: 651-439-2663
Mailing address:
  • Phone: 651-439-2712
  • Fax: 651-439-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL LARSEN
Title or Position: CEO
Credential: DC
Phone: 651-439-2712