Provider Demographics
NPI:1780783506
Name:ADVANCED REHAB, PC
Entity type:Organization
Organization Name:ADVANCED REHAB, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-495-8995
Mailing Address - Street 1:417 N BENTON AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-5041
Mailing Address - Country:US
Mailing Address - Phone:406-495-8995
Mailing Address - Fax:406-495-8996
Practice Address - Street 1:1005 PARTRIDGE PL STE 2
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-0528
Practice Address - Country:US
Practice Address - Phone:406-495-8995
Practice Address - Fax:406-495-8996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPT1007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT3401008Medicaid
MT3401020Medicaid