Provider Demographics
NPI:1689935942
Name:WILDROSE HOME MEDICAL
Entity Type:Organization
Organization Name:WILDROSE HOME MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESTLEY
Authorized Official - Middle Name:T
Authorized Official - Last Name:BLOMME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-618-5313
Mailing Address - Street 1:1210 E COLLEGE DR STE 800
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2269
Mailing Address - Country:US
Mailing Address - Phone:612-618-5313
Mailing Address - Fax:
Practice Address - Street 1:1210 E COLLEGE DR STE 800
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2269
Practice Address - Country:US
Practice Address - Phone:612-618-5313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies