Provider Demographics
NPI:1366754434
Name:APPLE VALLEY MEDICAL CLINIC, LTD.
Entity type:Organization
Organization Name:APPLE VALLEY MEDICAL CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-953-9285
Mailing Address - Street 1:14655 GALAXIE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8575
Mailing Address - Country:US
Mailing Address - Phone:952-432-6161
Mailing Address - Fax:
Practice Address - Street 1:14655 GALAXIE AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-8575
Practice Address - Country:US
Practice Address - Phone:952-432-6161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:APPLE VALLEY MEDICAL CLINIC, LTD.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-06
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
858098OtherPREFERRED ONE
679251001OtherMEDICARE
CE7163OtherRAILROAD MEDICARE
55108OtherHEALTHPARTNERS
22345APOtherBLUEE CROSS BLUE SHIELD
C00152Medicare PIN