Healthcare Provider Details

I. General information

NPI: 1750499224
Provider Name (Legal Business Name): HOMER PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 PENNOCK ST
HOMER AK
99603-7223
US

IV. Provider business mailing address

4141 PENNOCK ST
HOMER AK
99603-7223
US

V. Phone/Fax

Practice location:
  • Phone: 907-235-3410
  • Fax: 907-235-3417
Mailing address:
  • Phone: 907-235-3410
  • Fax: 907-235-3417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1134
License Number StateAK

VIII. Authorized Official

Name: SALLIE W REDISKE
Title or Position: OWNER
Credential: MPT
Phone: 907-235-3410