Healthcare Provider Details

I. General information

NPI: 1154302545
Provider Name (Legal Business Name): MINNESOTA MEDICAL AND REHABILITATIVE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date: 03/29/2022
Reactivation Date: 05/28/2022

III. Provider practice location address

4201 EXCELSIOR BLVD
ST. LOUIS PARK MN
55416-4728
US

IV. Provider business mailing address

4201 EXCELSIOR BLVD
ST LOUIS PARK MN
55416-4728
US

V. Phone/Fax

Practice location:
  • Phone: 952-564-3880
  • Fax: 952-945-9536
Mailing address:
  • Phone: 952-933-8900
  • Fax: 952-945-9536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1544
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5806
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2264
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number102980
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5169
License Number StateMN
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number6034
License Number StateMN

VIII. Authorized Official

Name: JACOB I MIRMAN
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 952-933-8900