1730390899 NPI number — SOUTHGATE PHYSICAL THERAPY , LTD

Table of content: (NPI 1730390899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730390899 NPI number — SOUTHGATE PHYSICAL THERAPY , LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHGATE PHYSICAL THERAPY , LTD
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:
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:
1730390899
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 CENTRE POINTE CURV
Provider Second Line Business Mailing Address:
#101
Provider Business Mailing Address City Name:
MENDOTA HEIGHTS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55120-1280
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-905-3783
Provider Business Mailing Address Fax Number:
651-686-4010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3017 BLOOMINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55407-1715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-721-7981
Provider Business Practice Location Address Fax Number:
612-721-7981
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRIMES
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
651-905-3783

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  669 , 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)





Copyright © 2007-2025 www.npivalidator.com