Provider Demographics
NPI:1821205923
Name:ROCKY MOUNTAIN SPORTS MEDICINE REHABILITATION LLC
Entity type:Organization
Organization Name:ROCKY MOUNTAIN SPORTS MEDICINE REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JAELYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KNUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-352-3626
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:THAYNE
Mailing Address - State:WY
Mailing Address - Zip Code:83127-0932
Mailing Address - Country:US
Mailing Address - Phone:307-883-4996
Mailing Address - Fax:307-352-3628
Practice Address - Street 1:416 W BLAIR AVE
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-7113
Practice Address - Country:US
Practice Address - Phone:307-352-3626
Practice Address - Fax:307-352-3628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty