Provider Demographics
NPI:1376996132
Name:MINNESOTA NATURAL MEDICINE
Entity Type:Organization
Organization Name:MINNESOTA NATURAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTEN
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:651-484-5567
Mailing Address - Street 1:3485 WILLOW LAKE BLVD
Mailing Address - Street 2:#100
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55110-5152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3485 WILLOW LAKE BLVD
Practice Address - Street 2:#100
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55110-5152
Practice Address - Country:US
Practice Address - Phone:651-484-5567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1061208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty