Provider Demographics
NPI:1457978983
Name:GLACIER PEAKS MOBILE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:GLACIER PEAKS MOBILE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:406-426-1560
Mailing Address - Street 1:PO BOX 5086
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-5086
Mailing Address - Country:US
Mailing Address - Phone:406-426-1560
Mailing Address - Fax:406-510-2933
Practice Address - Street 1:5068 US HIGHWAY 93 S STE 1
Practice Address - Street 2:
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-9179
Practice Address - Country:US
Practice Address - Phone:406-426-1560
Practice Address - Fax:406-510-2933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1457834822Medicaid