Provider Demographics
NPI:1104592229
Name:BENDER, MCKINLEY MADISON
Entity type:Individual
Prefix:
First Name:MCKINLEY
Middle Name:MADISON
Last Name:BENDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 S 34TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6061
Mailing Address - Country:US
Mailing Address - Phone:701-772-3851
Mailing Address - Fax:
Practice Address - Street 1:2200 LIBRARY CIR
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6326
Practice Address - Country:US
Practice Address - Phone:701-757-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist