Healthcare Provider Details

I. General information

NPI: 1669862843
Provider Name (Legal Business Name): GREAT METROPOLITAN BACKRUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 CLEVELAND AVE S
SAINT PAUL MN
55116-1347
US

IV. Provider business mailing address

762 CLEVELAND AVE S
SAINT PAUL MN
55116-1347
US

V. Phone/Fax

Practice location:
  • Phone: 651-698-3338
  • Fax: 612-729-1403
Mailing address:
  • Phone: 651-698-3338
  • Fax: 612-729-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: BARRY WOLF
Title or Position: BILLING MANAGER
Credential: MS
Phone: 239-970-2484