Healthcare Provider Details

I. General information

NPI: 1417870023
Provider Name (Legal Business Name): JEREMIAH TALLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 37TH AVE SW
MINOT ND
58701-7669
US

IV. Provider business mailing address

4801 38TH ST SE
MINOT ND
58701-2981
US

V. Phone/Fax

Practice location:
  • Phone: 701-418-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2897
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: