Healthcare Provider Details

I. General information

NPI: 1417653379
Provider Name (Legal Business Name): MOUNTAIN GOAT THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 02/02/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

968 REESE STREET
SILVERTON CO
81433-8143
US

IV. Provider business mailing address

PO BOX 822
SILVERTON CO
81433-0822
US

V. Phone/Fax

Practice location:
  • Phone: 913-244-3155
  • Fax:
Mailing address:
  • Phone: 913-244-3155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFF ROME
Title or Position: PT
Credential: PT, DPT
Phone: 913-244-3155