MEDICARE: KELLY DAVIS 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	10346	MN

General Provider Information

NPI Number	:	1396298832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY DAVIS DPT

Provider Business Mailing Address
First Line	:	7551 9TH ST N
Second Line	:	SUITE 100
City	:	OAKDALE
State	:	MN
Zip	:	55128-6629
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 VANDALIA ST
Second Line	:	SUITE 105
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1833
Country	:	US
Telephone Number	:	651-348-7428
Fax Number	:

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

Provider Enumeration Date	:	08/02/2016
Last Update Date	:	08/02/2016

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