Provider Demographics
NPI:1043259724
Name:PERFORMANCE PHYSICAL THERAPY, PC
Entity Type:Organization
Organization Name:PERFORMANCE PHYSICAL THERAPY, PC
Other - Org Name:PREMIER PHYSICAL THERAPY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:SPEARS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:406-846-7770
Mailing Address - Street 1:825 SAGEBRUSH LN STE 1
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722-2320
Mailing Address - Country:US
Mailing Address - Phone:406-846-7770
Mailing Address - Fax:406-846-7771
Practice Address - Street 1:600 MAIN ST
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722-1440
Practice Address - Country:US
Practice Address - Phone:406-846-7770
Practice Address - Fax:406-846-7771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT060833OtherBCBS
MT000084893Medicare ID - Type Unspecified
MT060833OtherBCBS