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General NPI Number Information
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NPI Number | 1215090501
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Entity Type | Organization
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Legal Business Name | BLOOMINGTON LAKE CLINIC, LTD
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 04/04/2011
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Provider Practice Location Address
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Address Line | 7901 XERXES AVE S STE 116
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City | BLOOMINGTON
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State | MN
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Zip | 55431-1200
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Country | US
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Telephone | 952-888-2024
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Fax | 952-888-3985
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Provider Business Mailing Address
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Address Line | 7901 XERXES AVE S STE 116
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City | BLOOMINGTON
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State | MN
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Zip | 55431-1200
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Country | US
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Telephone | 952-888-2024
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Fax | 952-888-3985
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Authorized Official
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Title or Position | ASSISTANT ADMINISTRATOR
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Name | DEBRA J BARGER
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Credential |
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Telephone | 612-277-2165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | 23
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License Number State | MN
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