Provider Demographics
NPI:1114074234
Name:ABC PEDIATRIC PHYSICAL THERAPY, LTD.
Entity Type:Organization
Organization Name:ABC PEDIATRIC PHYSICAL THERAPY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BORCHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:701-281-1864
Mailing Address - Street 1:7119 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:HORACE
Mailing Address - State:ND
Mailing Address - Zip Code:58047-4714
Mailing Address - Country:US
Mailing Address - Phone:701-281-1864
Mailing Address - Fax:701-281-1924
Practice Address - Street 1:7119 MAPLE LN
Practice Address - Street 2:
Practice Address - City:HORACE
Practice Address - State:ND
Practice Address - Zip Code:58047-4714
Practice Address - Country:US
Practice Address - Phone:701-281-1864
Practice Address - Fax:701-281-1924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
161391043815OtherCIGNA-PREFERRED ONE
ND5952001OtherBLUE CROSS BLUE SHIELD
ND54528Medicaid
107037OtherHEALTH PARTNERS