Healthcare Provider Details

I. General information

NPI: 1699217505
Provider Name (Legal Business Name): ERIC NEFSTEAD PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 W MAIN ST
OSAKIS MN
56360-8243
US

IV. Provider business mailing address

410 W MAIN ST
OSAKIS MN
56360-8243
US

V. Phone/Fax

Practice location:
  • Phone: 320-859-6217
  • Fax: 320-859-8114
Mailing address:
  • Phone: 320-859-6217
  • Fax: 320-859-8114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10463
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: