Healthcare Provider Details

I. General information

NPI: 1134378037
Provider Name (Legal Business Name): BRADLEY ALLEN HEINECK PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 SHADY OAK CT
WINONA MN
55987-6034
US

IV. Provider business mailing address

66 SHADY OAK CT
WINONA MN
55987-6034
US

V. Phone/Fax

Practice location:
  • Phone: 507-454-0000
  • Fax: 507-454-6724
Mailing address:
  • Phone: 507-454-0000
  • Fax: 507-454-6724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6129
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: