Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 11910 | MN |
N | 2251S0007X | Physical Therapist - Sports |
NPI | 1154939171 |
---|---|
Provider Name | Charles Broback |
First Address | Minneapolis, MN 55413-1907 |
Second Address | Golden Valley, MN 55427-4475 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/07/2020 |
Last Update Date | 21/07/2020 |