Provider Demographics
NPI:1467589101
Name:PEQUOT LAKES PHYSICAL THERAPY SERVICES, INC
Entity Type:Organization
Organization Name:PEQUOT LAKES PHYSICAL THERAPY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WULF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-568-5666
Mailing Address - Street 1:31170 GOVERMENT DR
Mailing Address - Street 2:PO BOX 331
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-1001
Mailing Address - Country:US
Mailing Address - Phone:218-568-5666
Mailing Address - Fax:218-568-5466
Practice Address - Street 1:31170 GOVERMENT DR
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472-1001
Practice Address - Country:US
Practice Address - Phone:218-568-5666
Practice Address - Fax:218-568-5466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02960Medicare ID - Type Unspecified