Provider Demographics
NPI:1780822486
Name:JACK V, LUNDBOHM INC
Entity Type:Organization
Organization Name:JACK V, LUNDBOHM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:V
Authorized Official - Last Name:LUNDBOHM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-463-2992
Mailing Address - Street 1:317 2ND ST NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEAU
Mailing Address - State:MN
Mailing Address - Zip Code:56751-1070
Mailing Address - Country:US
Mailing Address - Phone:218-463-2992
Mailing Address - Fax:218-463-1229
Practice Address - Street 1:317 2ND ST NW
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEAU
Practice Address - State:MN
Practice Address - Zip Code:56751-1070
Practice Address - Country:US
Practice Address - Phone:218-463-2992
Practice Address - Fax:218-463-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1792261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center