Provider Demographics
NPI:1235332594
Name:LOLO PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:LOLO PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAFE
Authorized Official - Last Name:SANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-273-3730
Mailing Address - Street 1:PO BOX 1627
Mailing Address - Street 2:
Mailing Address - City:LOLO
Mailing Address - State:MT
Mailing Address - Zip Code:59847-1627
Mailing Address - Country:US
Mailing Address - Phone:406-273-3730
Mailing Address - Fax:406-273-9088
Practice Address - Street 1:106 TYLER WAY
Practice Address - Street 2:
Practice Address - City:LOLO
Practice Address - State:MT
Practice Address - Zip Code:59847-9714
Practice Address - Country:US
Practice Address - Phone:406-273-3730
Practice Address - Fax:406-273-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1263PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000342363Medicaid