MEDICARE: JOHNATHAN CICCHESE DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	10069	MN

General Provider Information

NPI Number	:	1073980793
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN CICCHESE DPT

Provider Business Mailing Address
First Line	:	2029 HENRY ST N
Second Line	:
City	:	NORTH SAINT PAUL
State	:	MN
Zip	:	55109-4114
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1747 BEAM AVE
Second Line	:	SUITE NUMBER 100
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-1128
Country	:	US
Telephone Number	:	651-326-5569
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2015
Last Update Date	:	08/28/2015

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