Provider Demographics
NPI:1598251639
Name:THE RESILIENT ATHLETE CENTER
Entity Type:Organization
Organization Name:THE RESILIENT ATHLETE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, SCS
Authorized Official - Phone:720-299-5398
Mailing Address - Street 1:3155 BLUESTEM DR # 288
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-8002
Mailing Address - Country:US
Mailing Address - Phone:701-353-5476
Mailing Address - Fax:
Practice Address - Street 1:3155 BLUESTEM DR # 288
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-8002
Practice Address - Country:US
Practice Address - Phone:701-353-5476
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND45290600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty