1043392087 NPI number — INSTITUTE OF PHYSICAL THERAPY AND FITNESS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043392087 NPI number — INSTITUTE OF PHYSICAL THERAPY AND FITNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INSTITUTE OF PHYSICAL THERAPY AND FITNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043392087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
678 SOUTHWAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501-3783
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-746-1418
Provider Business Mailing Address Fax Number:
208-746-4123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
678 SOUTHWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-3783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-746-1418
Provider Business Practice Location Address Fax Number:
208-746-4123
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OHMAN
Authorized Official First Name:
PEGGY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
208-746-1418

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8B263 . This is a "BCID GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0112038 . This is a "WA LI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 650006220 . This is a "RR MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 390090 . This is a "REGENCE GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 1000927 . This is a "CHAMPUS/BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 7023864 . This is a "WAPA GROUP" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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