Healthcare Provider Details

I. General information

NPI: 1861962318
Provider Name (Legal Business Name): COLE MOLITOR PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1894 37TH ST SE
SAINT CLOUD MN
56304-9508
US

IV. Provider business mailing address

419 8TH ST S
WAITE PARK MN
56387-1613
US

V. Phone/Fax

Practice location:
  • Phone: 320-227-2606
  • Fax:
Mailing address:
  • Phone: 320-290-6642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10686
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: