Healthcare Provider Details

I. General information

NPI: 1629239470
Provider Name (Legal Business Name): JAMES EDWARD PETTERS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13854 RIVERVIEW DRIVE NW
ELK RIVER MN
55330-1626
US

IV. Provider business mailing address

13854 RIVERVIEW DRIVE NW
ELK RIVER MN
55330-1626
US

V. Phone/Fax

Practice location:
  • Phone: 763-232-0818
  • Fax: 763-441-0487
Mailing address:
  • Phone: 763-232-0818
  • Fax: 763-441-0487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number4410
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: