Provider Demographics
NPI:1194740928
Name:POOR, GRANT DAMON (MS, PT)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:DAMON
Last Name:POOR
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:MT
Mailing Address - Zip Code:59436
Mailing Address - Country:US
Mailing Address - Phone:406-467-3800
Mailing Address - Fax:406-467-3828
Practice Address - Street 1:15 6TH ST S
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:MT
Practice Address - Zip Code:59436
Practice Address - Country:US
Practice Address - Phone:406-467-3800
Practice Address - Fax:406-467-3828
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1258 PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT60396OtherBC/BS OF MT
MT0340187Medicaid