Healthcare Provider Details

I. General information

NPI: 1568079523
Provider Name (Legal Business Name): TRAILHEAD HEALTH & REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1838 W PARKSIDE LN STE 110
PHOENIX AZ
85027-1370
US

IV. Provider business mailing address

PO BOX 5718
KALISPELL MT
59903-5718
US

V. Phone/Fax

Practice location:
  • Phone: 970-712-2938
  • Fax:
Mailing address:
  • Phone: 406-756-0134
  • Fax: 406-300-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: BLAINE STIMAC
Title or Position: MANAGING MEMBER
Credential:
Phone: 406-756-1128