Organization
ST. CLOUD EAR, NOSE & THROAT - SURGICAL SUITES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. LARRY R BOLLER RRT, MBA (ADMINISTRATOR)
(320) 252-0233
Entity
Organization
Contact information
Practice address
1528 NORTHWAY DR, SAINT CLOUD, MN 56303-1255
(320) 252-0233
(320) 257-1126
Mailing address
1528 NORTHWAY DR, SAINT CLOUD, MN 56303-1255
(320) 252-0233
(320) 252-1421
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
PENDING
—
Other
Enumeration date
08/03/2009
Last updated
08/03/2009
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