Healthcare Provider Details

I. General information

NPI: 1235674037
Provider Name (Legal Business Name): ORTHOPEDIC & SPINE THERAPY OF ALBERTVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5232 KYLER AVE NE STE C
ALBERTVILLE MN
55301-4634
US

IV. Provider business mailing address

5232 KYLER AVE NE STE C
ALBERTVILLE MN
55301-4775
US

V. Phone/Fax

Practice location:
  • Phone: 763-260-5313
  • Fax: 833-599-7671
Mailing address:
  • Phone: 763-260-5313
  • Fax: 833-599-7671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOSHUA AUGUSTUS CADWALLADER
Title or Position: OWNER
Credential: PT, DPT
Phone: 763-260-5313