Provider Demographics
NPI:1407362049
Name:PARKSIDE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PARKSIDE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-646-7068
Mailing Address - Street 1:PO BOX 1573
Mailing Address - Street 2:
Mailing Address - City:WEST YELLOWSTONE
Mailing Address - State:MT
Mailing Address - Zip Code:59758-1573
Mailing Address - Country:US
Mailing Address - Phone:406-646-7068
Mailing Address - Fax:406-646-7069
Practice Address - Street 1:235 FIREHOLE AVE
Practice Address - Street 2:
Practice Address - City:WEST YELLOWSTONE
Practice Address - State:MT
Practice Address - Zip Code:59758-1573
Practice Address - Country:US
Practice Address - Phone:406-646-7068
Practice Address - Fax:406-646-7069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty