Healthcare Provider Details

I. General information

NPI: 1598768228
Provider Name (Legal Business Name): IMR OF MN., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2005
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5101 VERNON AVE S STE 301
EDINA MN
55436-2164
US

IV. Provider business mailing address

PO BOX 390216
EDINA MN
55439-0216
US

V. Phone/Fax

Practice location:
  • Phone: 952-925-5687
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. DOUGLAS HANSON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 952-925-5687