Basic Information
| Provider Information | |||||||||
| NPI: | 1558486670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREMONT THERAPY GROUP | ||||||||
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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: | 03/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PHISTER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST 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 | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 307980 | 01 | MEDICARE PART B | OTHER | C65268 | 01 | RAILROAD MEDICARE | OTHER |