=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144598491
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEARTOOTH PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2011
-----------------------------------------------------
Last Update Date | 10/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1333 W 5TH ST SUITE 203
-----------------------------------------------------
City | SHERIDAN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82801-2752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-752-9335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 306
-----------------------------------------------------
City | BIG HORN
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82833-0306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-752-9335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SUPERVISOR
-----------------------------------------------------
Name | MISTY D GARDNER
-----------------------------------------------------
Credential | MS, DPT
-----------------------------------------------------
Telephone | 307-752-9335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT 1154
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------