Provider Demographics
NPI:1124671151
Name:MISSOULA PT
Entity type:Organization
Organization Name:MISSOULA PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ILES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:605-670-1985
Mailing Address - Street 1:220 BENTON AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8726
Mailing Address - Country:US
Mailing Address - Phone:605-670-1985
Mailing Address - Fax:
Practice Address - Street 1:220 BENTON AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8726
Practice Address - Country:US
Practice Address - Phone:605-670-1985
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-18
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty