MEDICARE: DEER LODGE VALLEY THERAPY

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	261QP2000X	Physical Therapy Clinic/Center	100PT	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750600375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEER LODGE VALLEY THERAPY

Provider Business Mailing Address
First Line	:	310 MAIN ST
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722-1000
Country	:	US
Telephone Number	:	406-846-3448
Fax Number	:	406-846-2298

Provider Business Practice Location Address
First Line	:	310 MAIN ST
Second Line	:
City	:	DEER LODGE
State	:	MT
Zip	:	59722-1000
Country	:	US
Telephone Number	:	406-846-3448
Fax Number	:	406-846-2298

Authorized Official
Title or Position	:	OWER/PHYSICAL THERAPIST
Name	:	MRS. RONDA WANGERIN
Credential	:	P.T.
Telephone Number	:	406-846-3448

Provider Enumeration Date	:	05/21/2010
Last Update Date	:	05/21/2010

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Directions to “DEER LODGE VALLEY THERAPY ” Practice Location

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