Provider Demographics
NPI:1750790358
Name:POOLMAN, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:POOLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 PEBBLE BEACH RD
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721-9002
Mailing Address - Country:US
Mailing Address - Phone:218-773-2142
Mailing Address - Fax:
Practice Address - Street 1:1 RALPH ENGELSTAD ARENA DR
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58203-2205
Practice Address - Country:US
Practice Address - Phone:701-777-3107
Practice Address - Fax:701-777-6974
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND143-95174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator