Provider Demographics
NPI:1104908805
Name:THE CENTER OF PHYSICAL THERAPY & WELLNESS
Entity type:Organization
Organization Name:THE CENTER OF PHYSICAL THERAPY & WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-542-6670
Mailing Address - Street 1:1515 S RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-3629
Mailing Address - Country:US
Mailing Address - Phone:406-542-6670
Mailing Address - Fax:406-542-5496
Practice Address - Street 1:1515 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-3629
Practice Address - Country:US
Practice Address - Phone:406-542-6670
Practice Address - Fax:406-542-5496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT786PT261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTMSF1176897OtherBUS. STATE FUND
MTCK2066OtherRR MEDICARE GROUP
MT000060648OtherBCBS
MT000083508Medicare ID - Type Unspecified
MT=========Medicare UPIN