Healthcare Provider Details

I. General information

NPI: 1285194324
Provider Name (Legal Business Name): LIVING LIFE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 ELK DR
MINOT ND
58701-5633
US

IV. Provider business mailing address

1720 SUNDOWN DR
MINOT ND
58701-8134
US

V. Phone/Fax

Practice location:
  • Phone: 701-720-6354
  • Fax: 701-839-4076
Mailing address:
  • Phone: 701-720-6354
  • Fax: 701-839-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TERESSA BROCK
Title or Position: PHYSICAL THERAPIST/ OWNER
Credential: PT
Phone: 701-720-6354