Basic Information
| Provider Information | |||||||||
| NPI: | 1144311176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANTZI | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | DOYLE | ||||||||
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| Credential: | PT, DPT, ATC, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | 9525125651 | ||||||||
| Practice Location | |||||||||
| Address1: | 9630 GROVE CIR N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553693464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635207870 | ||||||||
| FaxNumber: | 7635207580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 05/27/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7849 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2255A2300X | 1924 | MN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 2251S0007X | 070.018314 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2255A2300X | 096.003082 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.