MEDICARE: ZACHARY PORTER LASALLE PT

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	PT1868	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M011000800	OTHER	MT	PTAN

General Provider Information

NPI Number	:	1841413978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARY PORTER LASALLE PT

Provider Business Mailing Address
First Line	:	126 EMPIRE LOOP
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-2523
Country	:	US
Telephone Number	:	406-471-2022
Fax Number	:

Provider Business Practice Location Address
First Line	:	734 9TH ST W STE 12
Second Line	:
City	:	COLUMBIA FALLS
State	:	MT
Zip	:	59912-3858
Country	:	US
Telephone Number	:	406-471-2022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	11/08/2011

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