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General NPI Number Information
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NPI Number | 1386374593
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Entity Type | Organization
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Legal Business Name | PRIMARY ENT, L.L.C.
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Dates
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Enumeration Date | 06/13/2022
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Last Update Date | 11/17/2022
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Provider Practice Location Address
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Address Line | 14020 HWY 13 S STE 350
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City | SAVAGE
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State | MN
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Zip | 55378-7103
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Country | US
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Telephone | 952-395-2500
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Fax | 952-395-2501
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Provider Business Mailing Address
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Address Line | 6021 NORTHWOOD RDG
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City | BLOOMINGTON
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State | MN
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Zip | 55438-1282
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Country | US
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Telephone | 612-406-9966
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Fax |
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. JOHN LUTHER BOONE
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Credential | MD
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Telephone | 612-406-9966
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number |
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License Number State |
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