Provider Demographics
NPI:1275794661
Name:CHRISTOPHERSON, BRUCE A
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:A
Last Name:CHRISTOPHERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 CRABTREE BLVD
Mailing Address - Street 2:
Mailing Address - City:INTERNATIONAL FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56649-2174
Mailing Address - Country:US
Mailing Address - Phone:218-285-9297
Mailing Address - Fax:
Practice Address - Street 1:2209 CRABTREE BLVD
Practice Address - Street 2:
Practice Address - City:INTERNATIONAL FALLS
Practice Address - State:MN
Practice Address - Zip Code:56649-2174
Practice Address - Country:US
Practice Address - Phone:218-285-9297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1051213-1-AFC311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home