Provider Demographics
NPI:1477082709
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 1:3745 HARRISON AVE STE C
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-6814
Practice Address - Country:US
Practice Address - Phone:406-494-7050
Practice Address - Fax:406-494-1424
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONE PEAK PHYSICAL THERAPY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-09
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1477678969Medicaid