Provider Demographics
NPI:1437127834
Name:PARK AVENUE THERAPIES
Entity Type:Organization
Organization Name:PARK AVENUE THERAPIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:218-878-0805
Mailing Address - Street 1:1204 CLOQUET AVE
Mailing Address - Street 2:PO BOX 407
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-1622
Mailing Address - Country:US
Mailing Address - Phone:218-878-0805
Mailing Address - Fax:218-878-0794
Practice Address - Street 1:1204 CLOQUET AVE
Practice Address - Street 2:
Practice Address - City:CLOQUET
Practice Address - State:MN
Practice Address - Zip Code:55720-1622
Practice Address - Country:US
Practice Address - Phone:218-878-0805
Practice Address - Fax:218-878-0794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4406225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN806518700Medicaid
DC4813OtherMEDICARE RAILROAD
MNN010204OtherTRICARE
MNN010204OtherTRICARE