Healthcare Provider Details

I. General information

NPI: 1396303947
Provider Name (Legal Business Name): WESTON MARK OBRYCKI DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2019
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1398 LAKE ST S STE 100
FOREST LAKE MN
55025-2720
US

IV. Provider business mailing address

4200 DAHLBERG DR STE 300
GOLDEN VALLEY MN
55422-4841
US

V. Phone/Fax

Practice location:
  • Phone: 651-275-2700
  • Fax: 651-309-0000
Mailing address:
  • Phone: 952-512-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11468
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: