Healthcare Provider Details

I. General information

NPI: 1972729176
Provider Name (Legal Business Name): HOLLY MARIE GROSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/31/2008
Certification Date:
Deactivation Date: 02/01/2008
Reactivation Date: 07/31/2008

III. Provider practice location address

15 E 1ST AVE N
AURORA MN
55705-1386
US

IV. Provider business mailing address

15 E 1ST AVE N
AURORA MN
55705-1386
US

V. Phone/Fax

Practice location:
  • Phone: 218-229-2300
  • Fax: 218-229-2005
Mailing address:
  • Phone: 218-229-2300
  • Fax: 218-229-2005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5727
License Number StateMN

VIII. Authorized Official

Name: MRS. HOLLY MARIE GROSS
Title or Position: OWNER
Credential: PT
Phone: 218-229-2300