Individual
DARIN ERP
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, DPT
Contact information
Practice address
3400 NEBRASKA DR, BISMARCK, ND 58503-1649
(701) 223-3040
Mailing address
200 LEWIS AVE S STE 210, WATERTOWN, MN 55388-4547
(952) 955-2242
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
1597
ND
Other
Enumeration date
11/07/2014
Last updated
03/17/2018
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