Provider Demographics
NPI:1700301884
Name:ADVANTAGE THERAPY
Entity Type:Organization
Organization Name:ADVANTAGE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BARIBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:218-780-4554
Mailing Address - Street 1:227 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:EVELETH
Mailing Address - State:MN
Mailing Address - Zip Code:55734-1606
Mailing Address - Country:US
Mailing Address - Phone:218-780-4554
Mailing Address - Fax:218-744-9631
Practice Address - Street 1:227 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:EVELETH
Practice Address - State:MN
Practice Address - Zip Code:55734-1606
Practice Address - Country:US
Practice Address - Phone:218-780-4554
Practice Address - Fax:218-744-9631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2017-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6361225100000X
MN101012225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty