Provider Demographics
NPI:1467673715
Name:WESTLAKE, TODD MICHAEL (CPO)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:MICHAEL
Last Name:WESTLAKE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22990 FAWN TRL
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-8740
Mailing Address - Country:US
Mailing Address - Phone:763-428-5453
Mailing Address - Fax:
Practice Address - Street 1:606 24TH AVE S
Practice Address - Street 2:SUITE 301
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1455
Practice Address - Country:US
Practice Address - Phone:612-672-6653
Practice Address - Fax:612-672-4780
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCPO 1904222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN077842OtherFAIRVIEW HEATH SERVICES #