Provider Demographics
NPI:1699968404
Name:HOMESTEAD PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:HOMESTEAD PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:HERKSTROETER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:307-745-5434
Mailing Address - Street 1:PO BOX 1146
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073-1146
Mailing Address - Country:US
Mailing Address - Phone:307-745-5434
Mailing Address - Fax:307-745-5484
Practice Address - Street 1:1575 N 4TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2091
Practice Address - Country:US
Practice Address - Phone:307-745-5434
Practice Address - Fax:307-745-5484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYDC9388OtherMEDICARE RAILROAD CARRIER
WY01248/001OtherBLUE CROSS BLUE SHIELD
WYW9980Medicare PIN