Provider Demographics
NPI:1043874639
Name:VALVICK, PRENTICE
Entity Type:Individual
Prefix:
First Name:PRENTICE
Middle Name:
Last Name:VALVICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 MOUND AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-1645
Mailing Address - Country:US
Mailing Address - Phone:507-385-4300
Mailing Address - Fax:
Practice Address - Street 1:708 MOUND AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-1645
Practice Address - Country:US
Practice Address - Phone:507-385-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA15462251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA1546OtherBOARD OF PHYSICAL THERAPY