MEDICARE: MINNESOTA NATURAL MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	1061	MN

General Provider Information

NPI Number	:	1376996132
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINNESOTA NATURAL MEDICINE

Provider Business Mailing Address
First Line	:	3485 WILLOW LAKE BLVD
Second Line	:	#100
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5152
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3485 WILLOW LAKE BLVD
Second Line	:	#100
City	:	VADNAIS HEIGHTS
State	:	MN
Zip	:	55110-5152
Country	:	US
Telephone Number	:	651-484-5567
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	JONATHAN OTTEN
Credential	:	N.D.
Telephone Number	:	651-484-5567

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	07/18/2016

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