Basic Information
| Provider Information | |||||||||
| NPI: | 1356562235 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KNUDSEN | ||||||||
| FirstName: | BRUCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 86 SDS 12 2901 | ||||||||
| Address2: | |||||||||
| City: | MINNEAOPLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554862901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685050 | ||||||||
| FaxNumber: | 6519685900 | ||||||||
| Practice Location | |||||||||
| Address1: | 2090 WOODWINDS DRIVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519685802 | ||||||||
| FaxNumber: | 6519685898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 10/26/2009 | ||||||||
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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 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5299 | 01 | MN | LICENSE# | OTHER |