Provider Demographics
NPI:1669829164
Name:TEMBROCK, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:TEMBROCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 COUNTY ROAD 120
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4872
Mailing Address - Country:US
Mailing Address - Phone:320-259-5429
Mailing Address - Fax:320-240-8905
Practice Address - Street 1:251 COUNTY ROAD 120
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4872
Practice Address - Country:US
Practice Address - Phone:320-259-5429
Practice Address - Fax:320-240-8905
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210154225100000X
MN10472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0064-0032705OtherMEDICA
MN0064-0032705OtherMEDICA