Healthcare Provider Details

I. General information

NPI: 1194097337
Provider Name (Legal Business Name): THE AMAZING JOURNEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 04/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7658 DESIGN RD SUITE 300
BAXTER MN
56425-8439
US

IV. Provider business mailing address

7658 DESIGN RD SUITE 300
BAXTER MN
56425-8439
US

V. Phone/Fax

Practice location:
  • Phone: 218-454-4600
  • Fax: 218-454-4601
Mailing address:
  • Phone: 218-454-4600
  • Fax: 218-454-4601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number8645
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number104320
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8993
License Number StateMN

VIII. Authorized Official

Name: RYAN MEYER
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 218-454-4600