Provider Demographics
NPI:1093089740
Name:GRANITE SPORTS MEDICINE
Entity Type:Organization
Organization Name:GRANITE SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/STAFF PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:K
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:406-223-2763
Mailing Address - Street 1:1014 W PARK ST STE 4
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-2541
Mailing Address - Country:US
Mailing Address - Phone:406-223-2763
Mailing Address - Fax:
Practice Address - Street 1:1014 W PARK ST STE 4
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:MT
Practice Address - Zip Code:59047-2541
Practice Address - Country:US
Practice Address - Phone:406-223-2763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1794261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy