Provider Demographics
NPI:1235673708
Name:LONE PEAK PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:LONE PEAK PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOERSMA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, OCS
Authorized Official - Phone:406-522-7488
Mailing Address - Street 1:PO BOX 11629
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59719-1629
Mailing Address - Country:US
Mailing Address - Phone:406-522-7488
Mailing Address - Fax:406-522-7487
Practice Address - Street 1:312 W MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-3836
Practice Address - Country:US
Practice Address - Phone:406-388-2235
Practice Address - Fax:406-388-2281
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONE PEAK PHYSICAL THERAPY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-18
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT225100000X, 225X00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1477678969Medicaid