Provider Demographics
NPI:1316949340
Name:ACTIVE PHYSICAL THERAPY & SPORTS INJURY CENTER, LLC
Entity type:Organization
Organization Name:ACTIVE PHYSICAL THERAPY & SPORTS INJURY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MESSER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:406-829-9600
Mailing Address - Street 1:1410 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4701
Mailing Address - Country:US
Mailing Address - Phone:406-829-9600
Mailing Address - Fax:406-829-9602
Practice Address - Street 1:1410 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4701
Practice Address - Country:US
Practice Address - Phone:406-829-9600
Practice Address - Fax:406-829-9602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1758PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000085091Medicare PIN