Basic Information
| Provider Information | |||||||||
| NPI: | 1821029638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSENDAHL | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 S CAROL ST | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836461839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1511 HIGHWAY 59 S | ||||||||
| Address2: | SUITE A | ||||||||
| City: | THIEF RIVER FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567013413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2186810449 | ||||||||
| FaxNumber: | 2186810490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/22/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 6635 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P01328766 | 01 | MN | RAILROAD MEDICARE | OTHER | H400133424 | 01 | MN | MEDICARE PROVIDER # | OTHER |