=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326630955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOTIV PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2021
-----------------------------------------------------
Last Update Date | 02/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 W 1ST ST APT 3A
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55802-1683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-242-6217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 414 W 1ST ST APT 3A
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55802-1683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICAL THERAPIST
-----------------------------------------------------
Name | ALEX LOCH
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 763-242-6217
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------