Provider Demographics
NPI:1861067068
Name:GRAY DUCK PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:GRAY DUCK PHYSICAL THERAPY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:612-217-2154
Mailing Address - Street 1:299 COON RAPIDS BLVD NW STE 103
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5869
Mailing Address - Country:US
Mailing Address - Phone:612-217-2154
Mailing Address - Fax:612-447-0159
Practice Address - Street 1:299 COON RAPIDS BLVD NW STE 103
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5869
Practice Address - Country:US
Practice Address - Phone:612-217-2154
Practice Address - Fax:612-447-0159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty