Provider Demographics
NPI:1558742981
Name:BACK COUNTRY PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:BACK COUNTRY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JENKS
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:307-461-9669
Mailing Address - Street 1:PO BOX 7220
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-7004
Mailing Address - Country:US
Mailing Address - Phone:307-461-9669
Mailing Address - Fax:307-333-0355
Practice Address - Street 1:2240 COFFEEN AVE
Practice Address - Street 2:STE G
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6288
Practice Address - Country:US
Practice Address - Phone:307-461-9669
Practice Address - Fax:307-333-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty