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General NPI Number Information
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NPI Number | 1104908805
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Entity Type | Organization
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Legal Business Name | THE CENTER OF PHYSICAL THERAPY & WELLNESS
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Dates
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Enumeration Date | 10/20/2006
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 1515 S RUSSELL ST
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City | MISSOULA
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State | MT
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Zip | 59801-3629
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Country | US
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Telephone | 406-542-6670
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Fax | 406-542-5496
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Provider Business Mailing Address
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Address Line | 1515 S RUSSELL ST
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City | MISSOULA
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State | MT
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Zip | 59801-3629
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Country | US
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Telephone | 406-542-6670
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Fax | 406-542-5496
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MRS. SHELLEY ANN SULLIVAN
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Credential | P.T.
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Telephone | 406-542-6670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 786PT
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License Number State | MT
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