Healthcare Provider Details

I. General information

NPI: 1043240211
Provider Name (Legal Business Name): MIKE VIG P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 ATLANTIC AVE
MORRIS MN
56267-1380
US

IV. Provider business mailing address

820 ROY ST
ORTONVILLE MN
56278-1138
US

V. Phone/Fax

Practice location:
  • Phone: 320-585-5395
  • Fax: 320-839-4196
Mailing address:
  • Phone: 320-830-4271
  • Fax: 320-839-4196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7202
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0736
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: