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General NPI Number Information
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NPI Number | 1124671151
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Entity Type | Organization
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Legal Business Name | MISSOULA PT
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Dates
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Enumeration Date | 07/18/2019
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Last Update Date | 10/10/2019
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Provider Practice Location Address
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Address Line | 220 BENTON AVE
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City | MISSOULA
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State | MT
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Zip | 59801-8726
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Country | US
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Telephone | 605-670-1985
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Fax |
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Provider Business Mailing Address
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Address Line | 220 BENTON AVE
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City | MISSOULA
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State | MT
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Zip | 59801-8726
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Country | US
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Telephone | 605-670-1985
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Fax |
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Authorized Official
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Title or Position | OWNER, PHYSICAL THERAPIST
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Name | MARIA ILES
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Credential | DPT
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Telephone | 605-670-1985
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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