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General NPI Number Information
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NPI Number | 1366754434
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Entity Type | Organization
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Legal Business Name | APPLE VALLEY MEDICAL CLINIC, LTD.
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Dates
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Enumeration Date | 07/06/2010
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Last Update Date | 06/19/2017
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Provider Practice Location Address
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Address Line | 14655 GALAXIE AVE
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City | APPLE VALLEY
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State | MN
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Zip | 55124-8575
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Country | US
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Telephone | 952-432-6161
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Fax |
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Provider Business Mailing Address
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Address Line | 14655 GALAXIE AVE
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City | APPLE VALLEY
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State | MN
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Zip | 55124-8575
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Country | US
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Telephone | 952-432-6161
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. MARK POTTENGER
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Credential |
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Telephone | 952-953-9285
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 723
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License Number State | MN
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