Provider Demographics
NPI:1639650393
Name:BACKSTROM PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:BACKSTROM PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-351-0775
Mailing Address - Street 1:215 HIGHWAY 2 SW STE 103
Mailing Address - Street 2:
Mailing Address - City:RUGBY
Mailing Address - State:ND
Mailing Address - Zip Code:58368-2407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 HIGHWAY 2 SW STE 103
Practice Address - Street 2:
Practice Address - City:RUGBY
Practice Address - State:ND
Practice Address - Zip Code:58368-2407
Practice Address - Country:US
Practice Address - Phone:701-351-0775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1755261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1987654321Medicaid