1548831357 NPI number — BITTERROOT PELVIC THERAPY D/B/A WELLSPRING PELVIC HEALTH

Table of content: (NPI 1548831357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548831357 NPI number — BITTERROOT PELVIC THERAPY D/B/A WELLSPRING PELVIC HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BITTERROOT PELVIC THERAPY D/B/A WELLSPRING PELVIC HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548831357
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
179 FAIRWAY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59803-2404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-236-3124
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2831 FORT MISSOULA RD
Provider Second Line Business Practice Location Address:
BUILDING 2, SUITE 232
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59804-7479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-200-8488
Provider Business Practice Location Address Fax Number:
406-213-3518
Provider Enumeration Date:
07/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
GIBSON
Authorized Official First Name:
JANELLE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PHYSICAL THERAPIST/OWNER
Authorized Official Telephone Number:
806-236-3124

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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