MEDICARE: DIANA D BOCKLUND MS, LAT, ATC, FF/EMT

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	2255A2300X	Athletic Trainer	2704	MN

General Provider Information

NPI Number	:	1588138051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA D BOCKLUND MS, LAT, ATC, FF/EMT

Provider Business Mailing Address
First Line	:	7820 64TH ST N
Second Line	:
City	:	PINE SPRINGS
State	:	MN
Zip	:	55115-6805
Country	:	US
Telephone Number	:	651-247-7315
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 DAHLBERG DR STE 300
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-4841
Country	:	US
Telephone Number	:	651-247-7315
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/17/2019
Last Update Date	:	01/17/2019

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