Provider Demographics
NPI:1629315866
Name:RICK, THEODORE JAMES (LMT,CMT)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JAMES
Last Name:RICK
Suffix:
Gender:M
Credentials:LMT,CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6009 WAYZATA BLVD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1223
Mailing Address - Country:US
Mailing Address - Phone:952-922-1478
Mailing Address - Fax:952-922-0248
Practice Address - Street 1:6009 WAYZATA BLVD
Practice Address - Street 2:SUITE 106
Practice Address - City:SAINT LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1223
Practice Address - Country:US
Practice Address - Phone:952-922-1478
Practice Address - Fax:952-922-0248
Is Sole Proprietor?:No
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00022480225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist