Provider Demographics
NPI:1770795924
Name:MONTICELLO PHYSICAL THERAPY & SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:MONTICELLO PHYSICAL THERAPY & SPORTS MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST -OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:STOKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-963-2023
Mailing Address - Street 1:307 MAPLE AVE. S
Mailing Address - Street 2:PO BOX 834
Mailing Address - City:MAPLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55358
Mailing Address - Country:US
Mailing Address - Phone:320-963-2023
Mailing Address - Fax:320-963-2023
Practice Address - Street 1:1125 S CEDAR STREET SUITE 103
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362
Practice Address - Country:US
Practice Address - Phone:763-295-4201
Practice Address - Fax:763-295-3895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5232225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty