MEDICARE: LOLO PHYSICAL THERAPY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1263PT	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235332594
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOLO PHYSICAL THERAPY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1627
Second Line	:
City	:	LOLO
State	:	MT
Zip	:	59847-1627
Country	:	US
Telephone Number	:	406-273-3730
Fax Number	:	406-273-9088

Provider Business Practice Location Address
First Line	:	106 TYLER WAY
Second Line	:
City	:	LOLO
State	:	MT
Zip	:	59847-9714
Country	:	US
Telephone Number	:	406-273-3730
Fax Number	:	406-273-9088

Authorized Official
Title or Position	:	OWNER PHYSICAL THERAPIST
Name	:	MR. MICHAEL RAFE SANDRY
Credential	:	P.T.
Telephone Number	:	406-273-3730

Provider Enumeration Date	:	06/06/2007
Last Update Date	:	11/08/2007

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