Healthcare Provider Details

I. General information

NPI: 1508535170
Provider Name (Legal Business Name): SISU PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2021
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2072 E CENTER CIR
PLYMOUTH MN
55441-3802
US

IV. Provider business mailing address

2072 E CENTER CIR
PLYMOUTH MN
55441-3802
US

V. Phone/Fax

Practice location:
  • Phone: 920-988-5893
  • Fax:
Mailing address:
  • Phone: 920-988-5893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: THOMAS RICHARDS
Title or Position: OWNER
Credential:
Phone: 612-998-3590