=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326521865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING MENAGERIE ACRES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2018
-----------------------------------------------------
Last Update Date | 05/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13691 PINEVIEW LN N
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55327-9461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-496-7881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13691 PINEVIEW LN N
-----------------------------------------------------
City | DAYTON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55327-9461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-496-7881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | LISA BRITTANY SANCHEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 763-496-7881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------