Provider Demographics
NPI:1134874654
Name:SOUTHSHORE PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:SOUTHSHORE PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:701-891-2043
Mailing Address - Street 1:104 12TH AVE NW UNIT 5
Mailing Address - Street 2:
Mailing Address - City:HAZEN
Mailing Address - State:ND
Mailing Address - Zip Code:58545-4106
Mailing Address - Country:US
Mailing Address - Phone:701-891-2043
Mailing Address - Fax:
Practice Address - Street 1:104 12TH AVE NW UNIT 5
Practice Address - Street 2:
Practice Address - City:HAZEN
Practice Address - State:ND
Practice Address - Zip Code:58545-4106
Practice Address - Country:US
Practice Address - Phone:701-891-2043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty