Provider Demographics
NPI:1336575711
Name:GREAT DIVIDE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:GREAT DIVIDE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:406-317-1121
Mailing Address - Street 1:2819 GREAT NORTHERN LOOP STE 300
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1750
Mailing Address - Country:US
Mailing Address - Phone:406-317-1121
Mailing Address - Fax:406-317-1875
Practice Address - Street 1:2819 GREAT NORTHERN LOOP STE 300
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1750
Practice Address - Country:US
Practice Address - Phone:406-317-1121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-18
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy