Provider Demographics
NPI:1700016037
Name:MIKA THERAPY LLC
Entity Type:Organization
Organization Name:MIKA THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-288-5328
Mailing Address - Street 1:13335 PALOMINO DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4248
Mailing Address - Country:US
Mailing Address - Phone:651-332-2539
Mailing Address - Fax:651-332-2540
Practice Address - Street 1:13335 PALOMINO DR
Practice Address - Street 2:SUITE 202
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4248
Practice Address - Country:US
Practice Address - Phone:651-332-2539
Practice Address - Fax:651-332-2540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2803227-2261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center