Provider Demographics
NPI:1073185393
Name:MAVERICK PHYSIOTHERAPY LLC
Entity Type:Organization
Organization Name:MAVERICK PHYSIOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MASON
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, PT
Authorized Official - Phone:715-271-0303
Mailing Address - Street 1:155 EATON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1602
Mailing Address - Country:US
Mailing Address - Phone:612-642-1847
Mailing Address - Fax:
Practice Address - Street 1:155 EATON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-1602
Practice Address - Country:US
Practice Address - Phone:612-642-1847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty