Provider Demographics
NPI:1487127825
Name:COUNTRYSIDE PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:COUNTRYSIDE PHYSICAL THERAPY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLEA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:605-390-4326
Mailing Address - Street 1:PO BOX 993
Mailing Address - Street 2:
Mailing Address - City:KILLDEER
Mailing Address - State:ND
Mailing Address - Zip Code:58640-0993
Mailing Address - Country:US
Mailing Address - Phone:605-390-4326
Mailing Address - Fax:
Practice Address - Street 1:42 CENTRAL AVE S
Practice Address - Street 2:
Practice Address - City:KILLDEER
Practice Address - State:ND
Practice Address - Zip Code:58640-4000
Practice Address - Country:US
Practice Address - Phone:605-390-4326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy