Provider Demographics
NPI:1619305752
Name:LONE PEAK PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:LONE PEAK PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAMEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KABISCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-223-0478
Mailing Address - Street 1:630 BOARDWALK AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-4118
Mailing Address - Country:US
Mailing Address - Phone:406-548-6266
Mailing Address - Fax:406-548-6269
Practice Address - Street 1:630 BOARDWALK AVE STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4118
Practice Address - Country:US
Practice Address - Phone:406-548-6266
Practice Address - Fax:406-548-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTPPTLIC1729225100000X
MTOTPOTLIC997225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty