Healthcare Provider Details

I. General information

NPI: 1205747623
Provider Name (Legal Business Name): MASON GRIMES PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 STATE AVE STE 2
FARIBAULT MN
55021-6369
US

IV. Provider business mailing address

36270 COUNTY 14 BLVD
CANNON FALLS MN
55009-5238
US

V. Phone/Fax

Practice location:
  • Phone: 507-497-3790
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14382
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: