Provider Demographics
NPI:1154302545
Name:MINNESOTA MEDICAL AND REHABILITATIVE SERVICES, LLC
Entity type:Organization
Organization Name:MINNESOTA MEDICAL AND REHABILITATIVE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:LEON
Authorized Official - Middle Name:B
Authorized Official - Last Name:FRID
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-564-3880
Mailing Address - Street 1:4201 EXCELSIOR BLVD
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4728
Mailing Address - Country:US
Mailing Address - Phone:952-564-3880
Mailing Address - Fax:952-945-9536
Practice Address - Street 1:4201 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4728
Practice Address - Country:US
Practice Address - Phone:952-564-3880
Practice Address - Fax:952-945-9536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2022-11-30
Deactivation Date:2022-03-29
Deactivation Code:
Reactivation Date:2022-05-28
Provider Licenses
StateLicense IDTaxonomies
MN1544225100000X
MN5806225100000X
MN2264225100000X
MN102980225X00000X
MN5169235Z00000X
MN6034235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN407858600Medicaid
MN1154302545Medicaid
MN244505Medicare ID - Type Unspecified
MNC05590Medicare UPIN
MN407858600Medicaid