Provider Demographics
NPI:1255303095
Name:SUPREME PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:SUPREME PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:PRIEM
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:612-805-2741
Mailing Address - Street 1:5201 CHOWEN AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2121
Mailing Address - Country:US
Mailing Address - Phone:612-805-2741
Mailing Address - Fax:
Practice Address - Street 1:5201 CHOWEN AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-2121
Practice Address - Country:US
Practice Address - Phone:612-805-2741
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN349G0SUOtherBLUE CROSS/BLUE SHIELD
MN349G0SUOtherBLUE CROSS/BLUE SHIELD