Healthcare Provider Details

I. General information

NPI: 1093991093
Provider Name (Legal Business Name): MR. JEFFREY ALAN DONATELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2008
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15620 EDGEWOOD DR STE 240
BAXTER MN
56401-6984
US

IV. Provider business mailing address

500 CROSS ST
BIG STONE CITY SD
57216-8237
US

V. Phone/Fax

Practice location:
  • Phone: 218-454-7012
  • Fax: 218-454-7015
Mailing address:
  • Phone: 605-541-1140
  • Fax: 605-541-0109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number949-039
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8517
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: