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General NPI Number Information
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NPI Number | 1710618483
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Entity Type | Organization
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Legal Business Name | RED TAIL THERAPY LLC
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Dates
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Enumeration Date | 06/22/2022
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Last Update Date | 08/25/2022
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Provider Practice Location Address
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Address Line | 350 S WASHINGTON ST UNIT 5
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City | AFTON
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State | WY
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Zip | 83110-5106
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Country | US
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Telephone | 307-254-1353
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1111
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City | AFTON
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State | WY
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Zip | 83110-1111
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Country | US
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Telephone | 307-254-1353
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Fax |
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Authorized Official
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Title or Position | CEO, PHYSICAL THERAPIST
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Name | KENNETH SMITH
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Credential | PT
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Telephone | 307-368-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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