Healthcare Provider Details

I. General information

NPI: 1487579868
Provider Name (Legal Business Name): MOLLY RAE PENGRA PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 09/13/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 E KANSAS CITY ST STE 101
RAPID CITY SD
57701-2950
US

IV. Provider business mailing address

18 E KANSAS CITY ST STE 101
RAPID CITY SD
57701-2950
US

V. Phone/Fax

Practice location:
  • Phone: 605-348-9530
  • Fax:
Mailing address:
  • Phone: 605-348-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13518
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: