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General NPI Number Information
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NPI Number | 1780910802
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Entity Type | Organization
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Legal Business Name | SPORTS ORTHOPEDIC ADVANCED REHABILITATION, LLC
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Dates
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Enumeration Date | 10/23/2009
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Last Update Date | 11/07/2019
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Provider Practice Location Address
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Address Line | 4660 SLATER RD STE 240
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City | EAGAN
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State | MN
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Zip | 55122
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Country | US
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Telephone | 952-223-3339
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Fax | 952-314-1401
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Provider Business Mailing Address
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Address Line | 4660 SLATER RD STE 240
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City | EAGAN
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State | MN
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Zip | 55122-4047
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Country | US
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Telephone | 952-223-3339
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Fax | 952-314-1401
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TERESA L. GURIN
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Credential | M.D.
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Telephone | 952-223-3339
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 39052
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License Number State | MN
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