Provider Demographics
NPI:1649277799
Name:BIGFORK PHYSICAL THERAPY & SPORTS REHABILITATION INC
Entity type:Organization
Organization Name:BIGFORK PHYSICAL THERAPY & SPORTS REHABILITATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JON
Authorized Official - Last Name:CLOSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:406-837-6892
Mailing Address - Street 1:PO BOX 1527
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MT
Mailing Address - Zip Code:59911-1527
Mailing Address - Country:US
Mailing Address - Phone:406-837-6892
Mailing Address - Fax:406-837-6435
Practice Address - Street 1:6400 MT HWY 35
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MT
Practice Address - Zip Code:59911
Practice Address - Country:US
Practice Address - Phone:406-837-6892
Practice Address - Fax:406-837-6435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1350PT261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000345185Medicaid
MT61996OtherBLUE CROSS BLUE SHIELD