Healthcare Provider Details

I. General information

NPI: 1821205394
Provider Name (Legal Business Name): ORTHOPEDIC & SPORTS REHABILIATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7872 CENTURY BLVD
CHANHASSEN MN
55317-8005
US

IV. Provider business mailing address

7872 CENTURY BLVD
CHANHASSEN MN
55317-8005
US

V. Phone/Fax

Practice location:
  • Phone: 952-448-9081
  • Fax: 952-448-9088
Mailing address:
  • Phone: 952-448-9081
  • Fax: 952-448-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number6935
License Number StateMN

VIII. Authorized Official

Name: RUSTY WALLMAN
Title or Position: OWNER
Credential:
Phone: 952-448-9081