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General NPI Number Information
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NPI Number | 1619978228
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Entity Type | Organization
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Legal Business Name | CAPERNAUM PEDIATRIC THERAPY, INC.
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Dates
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Enumeration Date | 08/04/2005
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Last Update Date | 02/13/2020
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Provider Practice Location Address
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Address Line | 6625 LYNDALE AVE S STE 430
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City | RICHFIELD
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State | MN
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Zip | 55423-2373
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Country | US
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Telephone | 952-285-2840
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Fax | 952-285-2830
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Provider Business Mailing Address
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Address Line | 6625 LYNDALE AVE S STE 430
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City | RICHFIELD
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State | MN
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Zip | 55423-2373
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Country | US
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Telephone | 952-285-2840
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Fax | 952-285-2830
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Authorized Official
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Title or Position | PHYSICAL THERAPIST/OWNER
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Name | MRS. BONNA OLSON
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Credential | PT
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Telephone | 952-285-2840
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 2304
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License Number State | MN
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