1184612772 NPI number — HAILEY SPORT AND SPINE PHYSICAL THERAPY PA

Table of content: (NPI 1184612772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184612772 NPI number — HAILEY SPORT AND SPINE PHYSICAL THERAPY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HAILEY SPORT AND SPINE PHYSICAL THERAPY PA
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:
HAILEY SPORT AND SPINE
Provider Other Organization Name Type Code:
3
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:
1184612772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1693
Provider Second Line Business Mailing Address:
810 S MAIN ST STE 7A
Provider Business Mailing Address City Name:
HAILEY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83333-1693
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-788-6312
Provider Business Mailing Address Fax Number:
208-578-1053

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
810 S MAIN ST
Provider Second Line Business Practice Location Address:
STE 7A
Provider Business Practice Location Address City Name:
HAILEY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83333-8426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-788-6312
Provider Business Practice Location Address Fax Number:
208-578-1053
Provider Enumeration Date:
10/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MAZIK
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-788-6312

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1168 , 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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