1356633275 NPI number — DR. ROBYN LOUISE BROSTROM-MARTIN D.C

Table of content: DR. ROBYN LOUISE BROSTROM-MARTIN D.C (NPI 1356633275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356633275 NPI number — DR. ROBYN LOUISE BROSTROM-MARTIN D.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROSTROM-MARTIN
Provider First Name:
ROBYN
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356633275
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18924 LAKE DR E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHANHASSEN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55317-9348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-474-1949
Provider Business Mailing Address Fax Number:
952-474-1959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
854 W 78TH ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
CHANHASSEN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55317-9506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-474-1949
Provider Business Practice Location Address Fax Number:
952-474-1959
Provider Enumeration Date:
05/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5516 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com