Healthcare Provider Details

I. General information

NPI: 1720432479
Provider Name (Legal Business Name): DEREK SWOBODA DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 W 6TH ST STE 101
SPENCER IA
51301-3906
US

IV. Provider business mailing address

710 8TH ST N
MOUNTAIN LAKE MN
56159-1308
US

V. Phone/Fax

Practice location:
  • Phone: 712-580-5008
  • Fax: 712-250-2415
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number111241
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: