Provider Demographics
NPI:1376678037
Name:THREE FORKS PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:THREE FORKS PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:HECOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-285-0626
Mailing Address - Street 1:PO BOX 1180
Mailing Address - Street 2:
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-1180
Mailing Address - Country:US
Mailing Address - Phone:406-285-0626
Mailing Address - Fax:406-285-3500
Practice Address - Street 1:203 S MAIN ST.
Practice Address - Street 2:
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752
Practice Address - Country:US
Practice Address - Phone:406-285-0626
Practice Address - Fax:406-285-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1278261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000061916OtherBLUE CROSS BLUE SHIELD
MT0345032Medicaid
MTP03975Medicare UPIN
MT000061916OtherBLUE CROSS BLUE SHIELD