MEDICARE: JACKSON HOLE SPORTS RECOVERY LLC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1255943098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON HOLE SPORTS RECOVERY LLC

Provider Business Mailing Address
First Line	:	PO BOX 880
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-0880
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	680 S CACHE ST STE 100
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8694
Country	:	US
Telephone Number	:	307-439-4247
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST, OWNER
Name	:	GIANNA RISOLI
Credential	:	PT
Telephone Number	:	307-439-4257

Provider Enumeration Date	:	08/22/2020
Last Update Date	:	08/31/2020

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