Healthcare Provider Details

I. General information

NPI: 1821052333
Provider Name (Legal Business Name): LADELL MERRITT PT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 AVENUE H
POWELL WY
82435-2260
US

IV. Provider business mailing address

PO BOX 1790
DOUGLAS WY
82633-1790
US

V. Phone/Fax

Practice location:
  • Phone: 307-754-1235
  • Fax: 307-754-3792
Mailing address:
  • Phone: 307-358-9464
  • Fax: 307-358-9330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-956
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: