MEDICARE: THEODORE JAMES RICK LMT,CMT

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	225700000X	Massage Therapist	00022480	MN

General Provider Information

NPI Number	:	1629315866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORE JAMES RICK LMT,CMT

Provider Business Mailing Address
First Line	:	6009 WAYZATA BLVD
Second Line	:	SUITE 106
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-1223
Country	:	US
Telephone Number	:	952-922-1478
Fax Number	:	952-922-0248

Provider Business Practice Location Address
First Line	:	6009 WAYZATA BLVD
Second Line	:	SUITE 106
City	:	SAINT LOUIS PARK
State	:	MN
Zip	:	55416-1223
Country	:	US
Telephone Number	:	952-922-1478
Fax Number	:	952-922-0248

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

Provider Enumeration Date	:	01/08/2013
Last Update Date	:	01/08/2013

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