=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891250635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSIYO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2019
-----------------------------------------------------
Last Update Date | 09/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8646 EAGLE CREEK CIR SUITE 109
-----------------------------------------------------
City | SAVAGE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55378-1572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-234-0377
-----------------------------------------------------
Fax | 612-324-7437
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21581 CREEKSIDE CIR
-----------------------------------------------------
City | LAKEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55044-8162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-249-8070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | CHRISTINA M HENKEL
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 952-234-0377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------