Provider Demographics
NPI:1972908945
Name:COPPER CITY PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:COPPER CITY PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCADAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-299-2450
Mailing Address - Street 1:1826 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-5406
Mailing Address - Country:US
Mailing Address - Phone:406-299-2450
Mailing Address - Fax:406-299-3117
Practice Address - Street 1:1826 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-5406
Practice Address - Country:US
Practice Address - Phone:406-299-2450
Practice Address - Fax:406-299-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-1675261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1972908945Medicaid