Provider Demographics
NPI:1649502881
Name:SYNERGY PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:SYNERGY PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HOLMQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:BSPT
Authorized Official - Phone:952-435-0343
Mailing Address - Street 1:10657 165TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-5670
Mailing Address - Country:US
Mailing Address - Phone:952-435-0343
Mailing Address - Fax:952-435-0344
Practice Address - Street 1:10657 165TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5670
Practice Address - Country:US
Practice Address - Phone:952-435-0343
Practice Address - Fax:952-435-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3080261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN955230800Medicaid