=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992849525
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISSOULA PHYSICAL THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 12/21/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1805 BANCROFT ST
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-5781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-543-4890
-----------------------------------------------------
Fax | 406-543-4892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1805 BANCROFT ST
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59801-5781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-543-4890
-----------------------------------------------------
Fax | 406-543-4892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EDITH G SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-543-4890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 218PT
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------