Provider Demographics
NPI:1841413978
Name:LASALLE, ZACHARY PORTER (PT)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:PORTER
Last Name:LASALLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 EMPIRE LOOP
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2523
Mailing Address - Country:US
Mailing Address - Phone:406-471-2022
Mailing Address - Fax:
Practice Address - Street 1:734 9TH ST W STE 12
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-3858
Practice Address - Country:US
Practice Address - Phone:406-471-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPT1868225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011000800OtherPTAN