Provider Demographics
NPI:1497304976
Name:GREAT FALLS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:GREAT FALLS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:703-349-1030
Mailing Address - Street 1:766 WALKER RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-2650
Mailing Address - Country:US
Mailing Address - Phone:703-349-1030
Mailing Address - Fax:703-364-5124
Practice Address - Street 1:766 WALKER RD STE B
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:VA
Practice Address - Zip Code:22066-2650
Practice Address - Country:US
Practice Address - Phone:703-349-1030
Practice Address - Fax:703-364-5124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-08
Last Update Date:2020-07-17
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
1508262734OtherNPI