Provider Demographics
NPI:1104295203
Name:THORSTENSON, KIP
Entity type:Individual
Prefix:
First Name:KIP
Middle Name:
Last Name:THORSTENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:ARGYLE
Mailing Address - State:MN
Mailing Address - Zip Code:56713-4002
Mailing Address - Country:US
Mailing Address - Phone:701-741-5549
Mailing Address - Fax:
Practice Address - Street 1:111 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ARGYLE
Practice Address - State:MN
Practice Address - Zip Code:56713-4002
Practice Address - Country:US
Practice Address - Phone:701-741-5549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist