Organization
NORTHERN LIGHTS ATHLETE VILLAGE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. STEPHANIE SMITH ATC (CEO)
(952) 888-4311
Entity
Organization
Contact information
Practice address
8109 BRYANT AVE S, BLOOMINGTON, MN 55420-5711
(952) 888-4311
Mailing address
8109 BRYANT AVE S, BLOOMINGTON, MN 55420-5711
(952) 888-4311
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
Primary
1411
MN
Other
Enumeration date
12/20/2007
Last updated
12/20/2007
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