Provider Demographics
NPI:1790831154
Name:PHYSICAL THERAPY CLINIC PC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CLINIC PC
Other - Org Name:PHYSICAL THERAPY CLINIC PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAL THERAPIST OWNER PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:HEIDI
Authorized Official - Last Name:PORATH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:307-864-4141
Mailing Address - Street 1:PO BOX 805
Mailing Address - Street 2:
Mailing Address - City:THERMOPOLIS
Mailing Address - State:WY
Mailing Address - Zip Code:82443
Mailing Address - Country:US
Mailing Address - Phone:307-864-4141
Mailing Address - Fax:
Practice Address - Street 1:305 BROADWAY
Practice Address - Street 2:
Practice Address - City:THERMOPOLIS
Practice Address - State:WY
Practice Address - Zip Code:82443
Practice Address - Country:US
Practice Address - Phone:307-864-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY277225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY304553Medicare ID - Type Unspecified