1073798476 NPI number — ELEMENTS OF WELLNESS AQUATIC AND MANUAL THERAPY INC.

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 1073798476 NPI number — ELEMENTS OF WELLNESS AQUATIC AND MANUAL THERAPY INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEMENTS OF WELLNESS AQUATIC AND MANUAL THERAPY INC.
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:
1073798476
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
872 TROY RD
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
MOSCOW
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83843-4046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-892-8888
Provider Business Mailing Address Fax Number:
208-882-8890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
872 TROY RD
Provider Second Line Business Practice Location Address:
SUITE 170
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-892-8888
Provider Business Practice Location Address Fax Number:
208-882-8890
Provider Enumeration Date:
01/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WILLBANKS
Authorized Official First Name:
DAYNA
Authorized Official Middle Name:
KATHLEEN
Authorized Official Title or Position:
OCCUPATIONAL THERAPIST OWNER
Authorized Official Telephone Number:
208-892-8888

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  OT-406 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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