Provider Demographics
NPI:1740797893
Name:OWATONNA SPORTS AND PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:OWATONNA SPORTS AND PHYSICAL THERAPY, INC
Other - Org Name:OWATONNA PHYSICAL THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LANI
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-451-8254
Mailing Address - Street 1:1414 S OAK AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-3957
Mailing Address - Country:US
Mailing Address - Phone:507-451-8254
Mailing Address - Fax:
Practice Address - Street 1:1414 S OAK AVE STE 2
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-3957
Practice Address - Country:US
Practice Address - Phone:507-451-8254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1356868442Medicaid