Provider Demographics
NPI:1023496320
Name:LONE PEAK PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:LONE PEAK PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOERSMA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:406-995-7525
Mailing Address - Street 1:PO BOX 11629
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59719-1629
Mailing Address - Country:US
Mailing Address - Phone:406-522-7488
Mailing Address - Fax:406-522-7487
Practice Address - Street 1:630 BOARDWALK AVE STE 1
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4118
Practice Address - Country:US
Practice Address - Phone:406-548-6266
Practice Address - Fax:406-548-6269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT000083080OtherMEDICARE PTAN
MT1477678969Medicaid