Provider Demographics
NPI:1770780876
Name:TWIN CITIES OCCUPATIONAL HEALTH AND REHABILITATION
Entity type:Organization
Organization Name:TWIN CITIES OCCUPATIONAL HEALTH AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAVERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-224-8264
Mailing Address - Street 1:10190 BALTIMORE STREET NORTH EAST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449
Mailing Address - Country:US
Mailing Address - Phone:763-780-8264
Mailing Address - Fax:763-780-8274
Practice Address - Street 1:10190 BALTIMORE STREET NORTH EAST
Practice Address - Street 2:SUITE 100
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449
Practice Address - Country:US
Practice Address - Phone:763-780-8264
Practice Address - Fax:763-780-8274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42667261QX0100X
MN30816261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN30816OtherMEDICAL LICENSE
MN42667OtherMEDICAL LICENSE
MN42667OtherMEDICAL LICENSE