Provider Demographics
NPI:1902255383
Name:PHENOM PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:PHENOM PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUTTURFF
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:320-543-1104
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:HOWARD LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55349-0737
Mailing Address - Country:US
Mailing Address - Phone:320-543-1104
Mailing Address - Fax:320-543-1105
Practice Address - Street 1:703 THIELEN DR
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-9613
Practice Address - Country:US
Practice Address - Phone:763-497-1153
Practice Address - Fax:763-497-5256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy