Provider Demographics
NPI:1851090039
Name:MUMFORD, EILEEN CAROL (LMT)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:CAROL
Last Name:MUMFORD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18519 ORCHARD TRL
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-6621
Mailing Address - Country:US
Mailing Address - Phone:612-913-2714
Mailing Address - Fax:
Practice Address - Street 1:1012 DIFFLEY RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1778
Practice Address - Country:US
Practice Address - Phone:612-913-2714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00005509225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist