Basic Information
| Provider Information | |||||||||
| NPI: | 1619077625 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODEN | ||||||||
| FirstName: | CINDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | RPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WIELAND | ||||||||
| OtherFirstName: | CINDY | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2401 DEMERS AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017801891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 S COLUMBIA RD | ||||||||
| Address2: | |||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017802300 | ||||||||
| FaxNumber: | 7636895558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
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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 | 645 | ND | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 54438 | 05 | ND | MEDICAID | 066R2BR | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | 616055700 | 05 | MN | MEDICAID | 15467 | 01 | ND | BLUE CROSS BLUE SHIELD | OTHER | 6411181 | 01 | MN | MEDICA | OTHER |