Healthcare Provider Details

I. General information

NPI: 1861097552
Provider Name (Legal Business Name): MWPT HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E CENTENNIAL 84 DR
NEW YORK MILLS MN
56567-4314
US

IV. Provider business mailing address

105 E CENTENNIAL 84 DR
NEW YORK MILLS MN
56567-4314
US

V. Phone/Fax

Practice location:
  • Phone: 218-371-8120
  • Fax:
Mailing address:
  • Phone: 218-371-8120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KIM ANDERSON
Title or Position: OWNER
Credential: PT
Phone: 218-371-8120