Healthcare Provider Details

I. General information

NPI: 1992865331
Provider Name (Legal Business Name): THOMAS JAY RHEAUME ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 KENWOOD AVE
DULUTH MN
55811-4199
US

IV. Provider business mailing address

4708 GLENWOOD ST
DULUTH MN
55804-1266
US

V. Phone/Fax

Practice location:
  • Phone: 218-723-5918
  • Fax: 218-723-5958
Mailing address:
  • Phone: 218-391-4693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1702
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: