Healthcare Provider Details

I. General information

NPI: 1962956995
Provider Name (Legal Business Name): BRANDON BOECK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 03/02/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1681 COMMERCE DR
NORTH MANKATO MN
56003-1913
US

IV. Provider business mailing address

7551 9TH ST N SUITE 100
SAINT PAUL MN
55128-6629
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-8017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10415
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: