Provider Demographics
NPI:1093035867
Name:CIMBURA, MACKENZE JOHN (DPT)
Entity Type:Individual
Prefix:
First Name:MACKENZE
Middle Name:JOHN
Last Name:CIMBURA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8510 49TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MONTPELIER
Mailing Address - State:ND
Mailing Address - Zip Code:58472-9706
Mailing Address - Country:US
Mailing Address - Phone:701-640-0074
Mailing Address - Fax:
Practice Address - Street 1:2422 20TH ST SW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-6201
Practice Address - Country:US
Practice Address - Phone:701-952-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist