Provider Demographics
NPI:1477568046
Name:FREMONT THERAPY GROUP LLC
Entity Type:Organization
Organization Name:FREMONT THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:PHISTER
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:307-856-7021
Mailing Address - Street 1:2002 WEST SUNSET DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501
Mailing Address - Country:US
Mailing Address - Phone:307-856-7021
Mailing Address - Fax:307-856-5546
Practice Address - Street 1:2002 WEST SUNSET DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501
Practice Address - Country:US
Practice Address - Phone:307-856-7021
Practice Address - Fax:307-856-5546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY111952400Medicaid
WY303969OtherBLUE CROSS BLUE SHIELD
1524243OtherUNITED MINEWORKERS
185794800OtherACS DEPT OF LABOR
C65268OtherRAILROAD MEDICARE
1172030001Medicare NSC
WY303969OtherBLUE CROSS BLUE SHIELD