=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851373880
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA L BLOOMQUIST M. D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2005
-----------------------------------------------------
Last Update Date | 09/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1675 COUNTY 6
-----------------------------------------------------
City | LA CRESCENT
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55947-9720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-790-0758
-----------------------------------------------------
Fax | 608-787-8911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 265
-----------------------------------------------------
City | LA CROSSE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54602-0265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-790-0758
-----------------------------------------------------
Fax | 608-787-8911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 31249
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------