MEDICARE: WESTERN TRAILS PHYSICAL THERAPY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2684	NE

General Provider Information

NPI Number	:	1700175619
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN TRAILS PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	1463 19TH AVE
Second Line	:	SUITE B
City	:	MITCHELL
State	:	NE
Zip	:	69357-1455
Country	:	US
Telephone Number	:	308-623-1313
Fax Number	:	308-623-1315

Provider Business Practice Location Address
First Line	:	1463 19TH AVE
Second Line	:	SUITE B
City	:	MITCHELL
State	:	NE
Zip	:	69357-1455
Country	:	US
Telephone Number	:	308-623-1313
Fax Number	:	308-623-1315

Authorized Official
Title or Position	:	OWNER/MANAGER/PRESIDENT
Name	:	JOHN WESLY BOWLIN
Credential	:	D.P.T.
Telephone Number	:	308-623-1313

Provider Enumeration Date	:	03/31/2011
Last Update Date	:	03/31/2011

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