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General NPI Number Information
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NPI Number | 1376136481
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Entity Type | Individual
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Provider Name | BRENT LEE JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 02/19/2021
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Last Update Date | 02/19/2021
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Provider Practice Location Address
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Address Line | 6401 FRANCE AVE S
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City | EDINA
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State | MN
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Zip | 55435-2199
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Country | US
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Telephone | 952-924-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 13243 BITTERSWEET ST NW
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City | COON RAPIDS
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State | MN
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Zip | 55448-1214
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 12100
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License Number State | MN
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