Basic Information
| Provider Information | |||||||||
| NPI: | 1083820971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAFT | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | ANNE | ||||||||
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| OtherLastName: | KRAFT | ||||||||
| OtherFirstName: | BECKY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3081 77TH ST NE | ||||||||
| Address2: | |||||||||
| City: | WILLOW CITY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583849641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017766152 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 S MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | RUGBY | ||||||||
| State: | ND | ||||||||
| PostalCode: | 583682118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017765261 | ||||||||
| FaxNumber: | 7017765448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1132 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 54527 | 05 | ND | MEDICAID |