Healthcare Provider Details

I. General information

NPI: 1255015921
Provider Name (Legal Business Name): BERUBE PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 9TH ST W
COLUMBIA FALLS MT
59912-3874
US

IV. Provider business mailing address

2035 CORTE DEL NOGAL STE 200
CARLSBAD CA
92011-1445
US

V. Phone/Fax

Practice location:
  • Phone: 406-206-4180
  • Fax:
Mailing address:
  • Phone: 760-931-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS POAN
Title or Position: CFO
Credential:
Phone: 760-931-8310