Healthcare Provider Details

I. General information

NPI: 1235332594
Provider Name (Legal Business Name): LOLO PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 TYLER WAY
LOLO MT
59847-9714
US

IV. Provider business mailing address

PO BOX 1627
LOLO MT
59847-1627
US

V. Phone/Fax

Practice location:
  • Phone: 406-273-3730
  • Fax: 406-273-9088
Mailing address:
  • Phone: 406-273-3730
  • Fax: 406-273-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1263PT
License Number StateMT

VIII. Authorized Official

Name: MR. MICHAEL RAFE SANDRY
Title or Position: OWNER PHYSICAL THERAPIST
Credential: P.T.
Phone: 406-273-3730