Healthcare Provider Details

I. General information

NPI: 1467007724
Provider Name (Legal Business Name): KEVAN PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5138 HORN RD
MISSOULA MT
59808-5217
US

IV. Provider business mailing address

5138 HORN RD
MISSOULA MT
59808-5217
US

V. Phone/Fax

Practice location:
  • Phone: 256-652-1772
  • Fax: 256-652-1772
Mailing address:
  • Phone: 205-942-6820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9461
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: