Provider Demographics
NPI:1932631405
Name:BIRCH BUNGALOW, LLC
Entity type:Organization
Organization Name:BIRCH BUNGALOW, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:MOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:218-770-9788
Mailing Address - Street 1:25212 COUNTY HIGHWAY 124
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-8266
Mailing Address - Country:US
Mailing Address - Phone:218-770-9788
Mailing Address - Fax:
Practice Address - Street 1:25212 COUNTY HIGHWAY 124
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-8266
Practice Address - Country:US
Practice Address - Phone:218-770-9788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BIRCH BUNGALOW, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2913261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center