Provider Demographics
NPI:1184009029
Name:PROXIMAL 50, INC
Entity Type:Organization
Organization Name:PROXIMAL 50, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:701-260-2693
Mailing Address - Street 1:1151 W. DIVIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501
Mailing Address - Country:US
Mailing Address - Phone:701-751-7797
Mailing Address - Fax:
Practice Address - Street 1:1151 W. DIVIDE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-751-7797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-21
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1964225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty