MEDICARE: INTEGRATED MOTION PEDIATRIC PHYSICAL THERAPY, 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	5428	MN

General Provider Information

NPI Number	:	1942377411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED MOTION PEDIATRIC PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	4540 OAK CHASE LN
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-2804
Country	:	US
Telephone Number	:	651-260-3774
Fax Number	:	651-688-6389

Provider Business Practice Location Address
First Line	:	4660 SLATER RD
Second Line	:	SUITE #130
City	:	EAGAN
State	:	MN
Zip	:	55122-4047
Country	:	US
Telephone Number	:	651-260-3774
Fax Number	:	651-688-6389

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. SARA STUTSMAN MASSARO
Credential	:	PT
Telephone Number	:	651-260-3774

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/22/2020

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