Healthcare Provider Details

I. General information

NPI: 1053821959
Provider Name (Legal Business Name): MADISON JUNE BENNETT PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MADISON JUNE VANCE PT

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 8TH AVE NE
HAZEN ND
58545-4600
US

IV. Provider business mailing address

510 8TH AVE NE
HAZEN ND
58545-4637
US

V. Phone/Fax

Practice location:
  • Phone: 701-748-2225
  • Fax:
Mailing address:
  • Phone: 605-515-0539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: