| NPI | 1396775110 |
|---|---|
| Doing Business As | GREAT RIVER SPINE & SPORT |
| Entity Type | Organization |
| Authorized Contact | BILL E MICKLE Owner 763-260-8401 |
| Organization Subpart ? | No |
| Primary Taxonomy | 225100000X Physical Therapist (Licence: MN 8397) |
| Additional Taxonomies | 207LP2900X Anesthesiology, Pain Medicine (Licence: MN 44760) |
| 2081P0004X Physical Medicine & Rehabilitation, Spinal Cord Injury Medicine (Licence: MN 44760) | |
| 2081P2900X Physical Medicine & Rehabilitation, Pain Medicine (Licence: 44760) | |
| 208VP0014X Pain Medicine, Interventional Pain Medicine (Licence: MN 44760) | |
| 363LF0000X Nurse Practitioner, Family (Licence: MN R182757-0) | |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2019-10-18 |