Provider Demographics
NPI:1558737551
Name:FILL-IN INTERIM THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:FILL-IN INTERIM THERAPY SERVICES, PLLC
Other - Org Name:FITS/FITNESS PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MAHLUM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-544-6090
Mailing Address - Street 1:91 CAMPUS DR
Mailing Address - Street 2:PMB 1217
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4492
Mailing Address - Country:US
Mailing Address - Phone:406-544-6090
Mailing Address - Fax:
Practice Address - Street 1:945 WYOMING STREET
Practice Address - Street 2:SUITE 135
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-544-6090
Practice Address - Fax:800-886-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-13
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT432225100000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1164591046OtherNPI
MT011000682OtherMEDICARE PTAN