=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144710906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DONNA DENISE SANDBERG L.AC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2018
-----------------------------------------------------
Last Update Date | 04/09/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4330 CEDAR LAKE RD S
-----------------------------------------------------
City | ST LOUIS PARK
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55416-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-250-9261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5210 VILLA WAY APT 358
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55436-2150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-250-9261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | 1852
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------