1043259724 NPI number — PERFORMANCE PHYSICAL THERAPY, PC

Table of content: (NPI 1043259724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043259724 NPI number — PERFORMANCE PHYSICAL THERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERFORMANCE PHYSICAL THERAPY, PC
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:
6
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:
1043259724
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 SAGEBRUSH LN STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEER LODGE
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59722-2320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-846-7770
Provider Business Mailing Address Fax Number:
406-846-7771

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER LODGE
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59722-1440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-846-7770
Provider Business Practice Location Address Fax Number:
406-846-7771
Provider Enumeration Date:
06/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPEARS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
SHANE
Authorized Official Title or Position:
PRESIDENT PHYSICAL THERAPIST
Authorized Official Telephone Number:
406-846-7770

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060833 . This is a "BCBS" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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