Healthcare Provider Details

I. General information

NPI: 1790261923
Provider Name (Legal Business Name): SCOTT JOSEPH CICHOS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 HIGHWAY 61 N
VADNAIS HEIGHTS MN
55110
US

IV. Provider business mailing address

5803 NEAL AVE N
OAK PARK HEIGHTS MN
55082-2177
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-8807
  • Fax: 651-439-0232
Mailing address:
  • Phone: 651-439-8807
  • Fax: 651-439-0232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11186
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: