MEDICARE: STEP AHEAD THERAPY OF ROSEAU INC

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

General Provider Information

NPI Number	:	1376131151
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STEP AHEAD THERAPY OF ROSEAU INC

Provider Business Mailing Address
First Line	:	27081 LOWER RICE LAKE RD
Second Line	:
City	:	BAGLEY
State	:	MN
Zip	:	56621-4307
Country	:	US
Telephone Number	:	218-469-0725
Fax Number	:

Provider Business Practice Location Address
First Line	:	2781 FREEWAY BLVD STE 160
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55430-1765
Country	:	US
Telephone Number	:	763-515-8799
Fax Number	:	763-244-8021

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JILL PEDERSON
Credential	:
Telephone Number	:	218-461-1120

Provider Enumeration Date	:	01/06/2021
Last Update Date	:	01/20/2021

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