Provider Demographics
NPI:1245608603
Name:SUMMIT PHYSICAL & SPORTS THERAPY GREEN RIVER, LLC
Entity Type:Organization
Organization Name:SUMMIT PHYSICAL & SPORTS THERAPY GREEN RIVER, LLC
Other - Org Name:SUMMIT PHYSICAL & SPORTS THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:307-875-4654
Mailing Address - Street 1:541 E FLAMING GORGE WAY
Mailing Address - Street 2:UNIT A
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-4363
Mailing Address - Country:US
Mailing Address - Phone:307-875-4654
Mailing Address - Fax:307-875-4741
Practice Address - Street 1:541 E FLAMING GORGE WAY
Practice Address - Street 2:UNIT A
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-4363
Practice Address - Country:US
Practice Address - Phone:307-875-4654
Practice Address - Fax:307-875-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty