=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942778097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SWEERE CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2018
-----------------------------------------------------
Last Update Date | 01/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2501 W 84TH ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-885-5444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 W 84TH ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55431-1602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-885-5444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF CLINICS AND RETAIL
-----------------------------------------------------
Name | MICHAEL R TENNISON
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 952-885-5441
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------