1629484449 NPI number — THOMAS LYSCIO D.P.T.

Table of content: THOMAS LYSCIO D.P.T. (NPI 1629484449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629484449 NPI number — THOMAS LYSCIO D.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LYSCIO
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.T.
Provider Gender Code:
M

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:
1629484449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8317 BASS LAKE RD
Provider Second Line Business Mailing Address:
APARTMENT 204
Provider Business Mailing Address City Name:
NEW HOPE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55428-5336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-330-2816
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1107 HART BLVD
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55362-8538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-295-6878
Provider Business Practice Location Address Fax Number:
763-271-6860
Provider Enumeration Date:
07/02/2014

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: 225100000X , with the licence number:  3167 , 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)

  • Identifier: 3167 . This is a "TEMPORARY PERMIT - PHYSICAL THERAPIST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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