MEDICARE: WHOLE BUILDERS COOPERATIVE

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	332BC3200X	Customized Equipment (DME)	BC003093	MN

General Provider Information

NPI Number	:	1437552312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLE BUILDERS COOPERATIVE

Provider Business Mailing Address
First Line	:	2928 5TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2928 5TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-2412
Country	:	US
Telephone Number	:	612-824-6567
Fax Number	:

Authorized Official
Title or Position	:	OWNER, SECY/TREASURER
Name	:	MS. MARCIA BETHKE
Credential	:
Telephone Number	:	612-987-1729

Provider Enumeration Date	:	10/06/2014
Last Update Date	:	10/06/2014

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