Healthcare Provider Details

I. General information

NPI: 1902255383
Provider Name (Legal Business Name): PHENOM PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 THIELEN DR
SAINT MICHAEL MN
55376-9613
US

IV. Provider business mailing address

PO BOX 737
HOWARD LAKE MN
55349-0737
US

V. Phone/Fax

Practice location:
  • Phone: 763-497-1153
  • Fax: 763-497-5256
Mailing address:
  • Phone: 320-543-1104
  • Fax: 320-543-1105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateMN

VIII. Authorized Official

Name: CRAIG L BUTTURFF
Title or Position: OWNER
Credential: MSPT
Phone: 320-543-1104