Provider Demographics
NPI:1215090501
Name:BLOOMINGTON LAKE CLINIC, LTD
Entity type:Organization
Organization Name:BLOOMINGTON LAKE CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-277-2165
Mailing Address - Street 1:7901 XERXES AVE S STE 116
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-1200
Mailing Address - Country:US
Mailing Address - Phone:952-888-2024
Mailing Address - Fax:952-888-3985
Practice Address - Street 1:7901 XERXES AVE S STE 116
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-1200
Practice Address - Country:US
Practice Address - Phone:952-888-2024
Practice Address - Fax:952-888-3985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1713OtherHEALTH PARTNERS
MN302510100Medicaid
MNC406OtherUCARE MINNESOTA
MN1713OtherHEALTH PARTNERS