Healthcare Provider Details

I. General information

NPI: 1609632363
Provider Name (Legal Business Name): RYAN RAYMOND ROLFES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 W. ST. GERMAIN ST. #300
ST CLOUD MN
56301-7729
US

IV. Provider business mailing address

2835 W. ST. GERMAIN ST. #300
ST CLOUD MN
56301-7729
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-4151
  • Fax: 320-259-5707
Mailing address:
  • Phone: 320-259-4151
  • Fax: 320-259-5707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA2206
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: