Provider Demographics
NPI:1710618483
Name:RED TAIL THERAPY LLC
Entity Type:Organization
Organization Name:RED TAIL THERAPY LLC
Other - Org Name:RED TAIL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:307-368-2300
Mailing Address - Street 1:PO BOX 1111
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-1111
Mailing Address - Country:US
Mailing Address - Phone:307-254-1353
Mailing Address - Fax:
Practice Address - Street 1:350 S WASHINGTON ST UNIT 5
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-5106
Practice Address - Country:US
Practice Address - Phone:307-254-1353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-22
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty