Basic Information
| Provider Information | |||||||||
| NPI: | 1154379998 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GILLETTE PHYSICAL THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7132 | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827177132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076824900 | ||||||||
| FaxNumber: | 3076877243 | ||||||||
| Practice Location | |||||||||
| Address1: | 1013 EAST BOXELDER | ||||||||
| Address2: | |||||||||
| City: | GILLETTE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827185536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076824900 | ||||||||
| FaxNumber: | 3076877243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | CLOUSTON | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3076824900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 120766100 | 05 | WY | MEDICAID |