Healthcare Provider Details

I. General information

NPI: 1417763640
Provider Name (Legal Business Name): MATT KURILLA PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

3800 AMERICAN BLVD W # 200
BLOOMINGTON MN
55431-4420
US

IV. Provider business mailing address

8851 GOODRICH RD APT 213
BLOOMINGTON MN
55437-1624
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone: 608-445-2523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA3033
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: