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General NPI Number Information
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NPI Number | 1780822486
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Entity Type | Organization
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Legal Business Name | JACK V, LUNDBOHM INC
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Dates
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Enumeration Date | 02/03/2009
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Last Update Date | 02/03/2009
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Provider Practice Location Address
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Address Line | 317 2ND ST NW SUITE A
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City | ROSEAU
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State | MN
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Zip | 56751-1070
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Country | US
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Telephone | 218-463-2992
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Fax | 218-463-1229
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Provider Business Mailing Address
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Address Line | 317 2ND ST NW SUITE A
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City | ROSEAU
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State | MN
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Zip | 56751-1070
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Country | US
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Telephone | 218-463-2992
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Fax | 218-463-1229
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JACK V LUNDBOHM
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Credential | D.C.
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Telephone | 218-463-2992
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 1792
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License Number State | MN
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