Provider Demographics
NPI:1801092366
Name:ELEMENT PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:ELEMENT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:CRAGO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:406-543-7860
Mailing Address - Street 1:2455 DIXON AVE
Mailing Address - Street 2:STE A
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8219
Mailing Address - Country:US
Mailing Address - Phone:406-543-7860
Mailing Address - Fax:406-543-7862
Practice Address - Street 1:2455 DIXON AVE
Practice Address - Street 2:STE A
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-8219
Practice Address - Country:US
Practice Address - Phone:406-543-7860
Practice Address - Fax:406-543-7862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1300PT261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000083903Medicare ID - Type Unspecified