Basic Information
| Provider Information | |||||||||
| NPI: | 1477568046 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREMONT THERAPY GROUP LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2002 WEST SUNSET DRIVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078567021 | ||||||||
| FaxNumber: | 3078565546 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 WEST SUNSET DRIVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 82501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3078567021 | ||||||||
| FaxNumber: | 3078565546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 10/08/2010 | ||||||||
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| AuthorizedOfficialLastName: | PHISTER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3078567021 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
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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 | 111952400 | 05 | WY | MEDICAID | 303969 | 01 | WY | BLUE CROSS BLUE SHIELD | OTHER | 1524243 | 01 | UNITED MINEWORKERS | OTHER | 185794800 | 01 | ACS DEPT OF LABOR | OTHER | C65268 | 01 | RAILROAD MEDICARE | OTHER |