Healthcare Provider Details

I. General information

NPI: 1902813637
Provider Name (Legal Business Name): MOUNTAIN LAND PERFORMANCE LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 BROADWATER AVE SUITE 3
BILLINGS MT
59102-4863
US

IV. Provider business mailing address

PO BOX 711185
SALT LAKE CITY UT
84171
US

V. Phone/Fax

Practice location:
  • Phone: 406-656-0950
  • Fax: 406-656-0970
Mailing address:
  • Phone: 801-942-3311
  • Fax: 801-942-5955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK ANDERSON
Title or Position: PRESIDENT
Credential: PT
Phone: 801-942-3311