Provider Demographics
NPI:1558690099
Name:BEAR LODGE REHABILITATION SERVICES, LLC
Entity Type:Organization
Organization Name:BEAR LODGE REHABILITATION SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:307-358-9464
Mailing Address - Street 1:PO BOX 1790
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-1790
Mailing Address - Country:US
Mailing Address - Phone:307-358-9464
Mailing Address - Fax:307-358-9330
Practice Address - Street 1:226 SOUTH HIGHWAY 585
Practice Address - Street 2:
Practice Address - City:SUNDANCE
Practice Address - State:WY
Practice Address - Zip Code:82729-0928
Practice Address - Country:US
Practice Address - Phone:307-283-3516
Practice Address - Fax:307-283-3515
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH PLATTE PHYSICAL THERAPY SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty