Provider Demographics
NPI:1174729123
Name:ASPEN PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:ASPEN PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:907-262-2596
Mailing Address - Street 1:PO BOX 3763
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-3763
Mailing Address - Country:US
Mailing Address - Phone:907-262-2596
Mailing Address - Fax:
Practice Address - Street 1:221 W. MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7540
Practice Address - Country:US
Practice Address - Phone:907-262-2596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK695225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
K153335Medicare ID - Type UnspecifiedGROUP NUMBER