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NPI Code Detail

MEDICARE: BLAKE DEIST DPT

MEDICARE: BLAKE DEIST 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
1225100000XPhysical TherapistMN

General Provider Information

NPI Number : 1568800571
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAKE DEIST DPT
Provider Business Mailing Address
First Line : 7414 W 22ND ST APT 302
Second Line :
City : SAINT LOUIS PARK
State : MN
Zip : 55426-2641
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3050 CENTRE POINTE DR STE 200
Second Line :
City : ROSEVILLE
State : MN
Zip : 55113-1179
Country : US
Telephone Number : 888-974-6636
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/12/2013
Last Update Date : 09/10/2014

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Directions to “ BLAKE DEIST DPT” Practice Location

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