1871581058 NPI number — PEAK PERFORMANCE PHYSICAL THERAPY PC

Table of content: (NPI 1871581058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871581058 NPI number — PEAK PERFORMANCE PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEAK 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:
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:
1871581058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 HARVE AVE
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
MISSOULA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59801-8332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-542-0808
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1940 HARVE AVE
Provider Second Line Business Practice Location Address:
STE2
Provider Business Practice Location Address City Name:
MISSOULA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59801-8332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-542-0808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OLSON
Authorized Official First Name:
JILL
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
406-542-0808

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1760174288 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1083346506 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366282436 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1063439024 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1215530159 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1407085640 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1194370270 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8822411 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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