Healthcare Provider Details

I. General information

NPI: 1083206163
Provider Name (Legal Business Name): PIVOTAL PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 E MAIN ST
LOVELL WY
82431-2004
US

IV. Provider business mailing address

PO BOX 395
LOVELL WY
82431-0395
US

V. Phone/Fax

Practice location:
  • Phone: 307-887-6202
  • Fax:
Mailing address:
  • Phone: 307-887-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: GREG R BURTON
Title or Position: OWNER
Credential:
Phone: 307-887-6202