MEDICARE: OPTIMAL SPORTS PHYSICAL THERAPY

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	PTP-PT-LIC-5810	MT

General Provider Information

NPI Number	:	1457888943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL SPORTS PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	1605 KNIGHT ST
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59601-2355
Country	:	US
Telephone Number	:	719-659-6088
Fax Number	:

Provider Business Practice Location Address
First Line	:	3150 N MONTANA AVE STE D
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59602-7804
Country	:	US
Telephone Number	:	406-502-1782
Fax Number	:	406-502-1783

Authorized Official
Title or Position	:	OWNER
Name	:	JOHNANNA C SULLIVAN
Credential	:	PT, DPT, OCS, SCS, A
Telephone Number	:	719-659-6088

Provider Enumeration Date	:	05/16/2017
Last Update Date	:	07/18/2019

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