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General NPI Number Information
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NPI Number | 1417763640
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Entity Type | Individual
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Provider Name | MATT KURILLA PTA
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Gender | Male
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Dates
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Enumeration Date | 12/03/2024
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Last Update Date | 12/03/2024
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Provider Practice Location Address
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Address Line | 3800 AMERICAN BLVD W # 200
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City | BLOOMINGTON
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State | MN
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Zip | 55431-4420
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Country | US
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Telephone | 952-831-8742
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Fax |
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Provider Business Mailing Address
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Address Line | 8851 GOODRICH RD APT 213
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City | BLOOMINGTON
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State | MN
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Zip | 55437-1624
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Country | US
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Telephone | 608-445-2523
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | A3033
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License Number State | MN
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