Basic Information
Provider Information | |||||||||
NPI: | 1063711778 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DANIEL A GULLOTTA PT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | POLSON PHYSICAL THERAPY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 211A MAIN ST | ||||||||
Address2: |   | ||||||||
City: | POLSON | ||||||||
State: | MT | ||||||||
PostalCode: | 598602119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4068838101 | ||||||||
FaxNumber: | 4068838102 | ||||||||
Practice Location | |||||||||
Address1: | 211A MAIN ST | ||||||||
Address2: |   | ||||||||
City: | POLSON | ||||||||
State: | MT | ||||||||
PostalCode: | 598602119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4068838101 | ||||||||
FaxNumber: | 4068838102 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2011 | ||||||||
LastUpdateDate: | 03/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GULLOTTA | ||||||||
AuthorizedOfficialFirstName: | DANIEL | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4068838101 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT, MA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 741 | MT | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.