Provider Demographics
NPI:1174628333
Name:ARCHAMBAULT, MARK L (PT, PHD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:L
Last Name:ARCHAMBAULT
Suffix:
Gender:M
Credentials:PT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5718
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-5718
Mailing Address - Country:US
Mailing Address - Phone:406-756-0134
Mailing Address - Fax:406-309-2579
Practice Address - Street 1:3854 VILLAGE SEVEN RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-2801
Practice Address - Country:US
Practice Address - Phone:719-574-8761
Practice Address - Fax:719-574-8236
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL0016304225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ00793ZOtherBLUE SHIELD PROV ID #
CA061548025OtherTIN
CAPT11380OtherCA LICENSE
CAP19548Medicare UPIN