=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295271054
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE K. TRZYNKA ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2017
-----------------------------------------------------
Last Update Date | 01/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1282 CONCORDIA AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-5479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-641-8853
-----------------------------------------------------
Fax | 651-641-8787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1282 CONCORDIA AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-5479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-641-8853
-----------------------------------------------------
Fax | 651-641-8787
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225500000X
-----------------------------------------------------
Taxonomy Name | Respiratory/Developmental/Rehabilitative Specialist/Technologist
-----------------------------------------------------
License Number | 1521
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------