Provider Demographics
NPI:1366478935
Name:HOME TOWN PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:HOME TOWN PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MILLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-457-7678
Mailing Address - Street 1:2310 PEGER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5315
Mailing Address - Country:US
Mailing Address - Phone:907-457-7678
Mailing Address - Fax:907-457-7677
Practice Address - Street 1:2310 PEGER RD STE 101
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5315
Practice Address - Country:US
Practice Address - Phone:907-457-7678
Practice Address - Fax:907-457-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK307473261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK153347Medicare ID - Type Unspecified