Healthcare Provider Details

I. General information

NPI: 1295047371
Provider Name (Legal Business Name): LOLO PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 TYLER WAY
LOLO MT
59847-9714
US

IV. Provider business mailing address

106 TYLER WAY
LOLO MT
59847-9714
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 Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number1263MT
License Number StateMT

VIII. Authorized Official

Name: MR. MICHAEL R SANDRY
Title or Position: DIRECTOR
Credential: P.T.
Phone: 406-273-3730