1033115084 NPI number — PHOENIX PHYSICAL THERAPY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033115084 NPI number — PHOENIX PHYSICAL THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX PHYSICAL THERAPY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SEEDS OF CHANGE HEALTH AND WELLNESS CENTER
Provider Other Organization Name Type Code:
3
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:
1033115084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4408 HARRIET AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55419-4851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-314-9419
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3939 W 69TH ST UNIT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDINA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55435-2001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-562-2420
Provider Business Practice Location Address Fax Number:
952-562-2421
Provider Enumeration Date:
06/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DORI
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
952-314-9419

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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