Provider Demographics
NPI:1386245298
Name:MOUNTAIN PHYSIO LLC
Entity type:Organization
Organization Name:MOUNTAIN PHYSIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DRECHSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:207-491-8989
Mailing Address - Street 1:PO BOX 10304
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-0304
Mailing Address - Country:US
Mailing Address - Phone:207-491-8989
Mailing Address - Fax:
Practice Address - Street 1:225 ASPEN DR UNIT 2
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8611
Practice Address - Country:US
Practice Address - Phone:207-491-8989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy