Provider Demographics
NPI:1447725213
Name:HORNER, DALLAS JOHN (PT, DPT)
Entity type:Individual
Prefix:
First Name:DALLAS
Middle Name:JOHN
Last Name:HORNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 E MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3818
Mailing Address - Country:US
Mailing Address - Phone:701-415-0000
Mailing Address - Fax:833-969-0195
Practice Address - Street 1:1702 E MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3818
Practice Address - Country:US
Practice Address - Phone:701-415-0000
Practice Address - Fax:833-969-0195
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
ND2459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty