Provider Demographics
NPI:1922396357
Name:FAIRBANKS PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:FAIRBANKS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-479-0623
Mailing Address - Street 1:315 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-2910
Mailing Address - Country:US
Mailing Address - Phone:907-456-7767
Mailing Address - Fax:907-456-8050
Practice Address - Street 1:1755 WESTWOOD WAY
Practice Address - Street 2:SUITE 7
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4064
Practice Address - Country:US
Practice Address - Phone:907-479-0623
Practice Address - Fax:888-761-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty