Basic Information
| Provider Information | |||||||||
| NPI: | 1225506413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELIN | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR STE 150 | ||||||||
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| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 14890 BEAVER DAM RD | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564016019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182971605 | ||||||||
| FaxNumber: | 3202451008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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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 | 6581 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.