Healthcare Provider Details

I. General information

NPI: 1013240175
Provider Name (Legal Business Name): PHYSICAL THERAPY FOR KIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 N FOREST EDGE DR
SISTERS OR
97759-2692
US

IV. Provider business mailing address

PO BOX 1475
SISTERS OR
97759-1475
US

V. Phone/Fax

Practice location:
  • Phone: 907-346-4096
  • Fax: 877-319-7365
Mailing address:
  • Phone: 907-346-4096
  • Fax: 907-346-4097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number783
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number783
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SHARON SKIDMORE
Title or Position: OWNER
Credential: P.T., D.P.T.
Phone: 907-346-4096