Provider Demographics
NPI:1154379998
Name:GILLETTE PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:GILLETTE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLOUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:307-682-4900
Mailing Address - Street 1:PO BOX 7132
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82717-7132
Mailing Address - Country:US
Mailing Address - Phone:307-682-4900
Mailing Address - Fax:307-687-7243
Practice Address - Street 1:1013 EAST BOXELDER
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5536
Practice Address - Country:US
Practice Address - Phone:307-682-4900
Practice Address - Fax:307-687-7243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY120766100Medicaid
WY20276Medicare PIN
WYDE0322Medicare PIN
WY20276Medicare ID - Type Unspecified
WY5767920001Medicare NSC