Basic Information
| Provider Information | |||||||||
| NPI: | 1649521626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SQUINOBAL | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | DAVITT | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ORTONVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562781357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394271 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | MORRIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562671380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208394271 | ||||||||
| FaxNumber: | 3208394196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2012 | ||||||||
| LastUpdateDate: | 10/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9193 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.