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General NPI Number Information
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NPI Number | 1598502361
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Entity Type | Organization
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Legal Business Name | OTTER SLIDE PEDIATRIC PHYSICAL THERAPY, LLC
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Dates
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Enumeration Date | 07/10/2024
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Last Update Date | 11/20/2024
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Provider Practice Location Address
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Address Line | 135 FAIRWAY DR
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City | MISSOULA
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State | MT
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Zip | 59803-2404
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Country | US
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Telephone | 406-312-9967
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Fax | 406-519-5542
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Provider Business Mailing Address
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Address Line | PO BOX 474
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City | MISSOULA
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State | MT
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Zip | 59806-0474
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Country | US
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Telephone | 406-312-9967
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | KILEY S EVERSOLE
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Credential | PT, DPT
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Telephone | 406-312-9967
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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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