Healthcare Provider Details

I. General information

NPI: 1508979535
Provider Name (Legal Business Name): ROCKY MOUNTAIN SPORTS MEDICINE AND REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 GATEWAY BLVD STE 2
ROCK SPRINGS WY
82901-6786
US

IV. Provider business mailing address

1401 GATEWAY BLVD UNIT 2
ROCK SPRINGS WY
82901-6727
US

V. Phone/Fax

Practice location:
  • Phone: 307-352-3626
  • Fax: 307-352-3628
Mailing address:
  • Phone: 307-352-3626
  • Fax: 307-352-3628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JAELYN ANN KNUDSON
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 307-352-3626