Provider Demographics
NPI:1851470462
Name:BETWEEN THE BRIDGES HEALING CENTER, LLC
Entity Type:Organization
Organization Name:BETWEEN THE BRIDGES HEALING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MISSY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-388-7488
Mailing Address - Street 1:45 TETON LN
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4814
Mailing Address - Country:US
Mailing Address - Phone:507-388-7488
Mailing Address - Fax:507-388-5680
Practice Address - Street 1:45 TETON LN
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4814
Practice Address - Country:US
Practice Address - Phone:507-388-7488
Practice Address - Fax:507-388-5680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37416204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN560320000Medicaid
MN560320000Medicaid
MNC03900Medicare PIN