=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811923535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPEDIC & SPORTS PHYSICAL THERAPY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2006
-----------------------------------------------------
Last Update Date | 01/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 5TH ST N
-----------------------------------------------------
City | BRECKENRIDGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56520-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-641-7725
-----------------------------------------------------
Fax | 218-641-6625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 5TH ST N
-----------------------------------------------------
City | BRECKENRIDGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56520-1426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-641-7725
-----------------------------------------------------
Fax | 218-641-6625
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. SHAWN MARIE KRAUSE ROBERTS
-----------------------------------------------------
Credential | PT/ATC
-----------------------------------------------------
Telephone | 218-641-7725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 6521
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1180
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------