1477510204 NPI number — MRS. THERESA MARGARET BRYNTESON O.T.

Table of content: MRS. THERESA MARGARET BRYNTESON O.T. (NPI 1477510204)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477510204 NPI number — MRS. THERESA MARGARET BRYNTESON O.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRYNTESON
Provider First Name:
THERESA
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
O.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WATERBURY
Provider Other First Name:
THERESA
Provider Other Middle Name:
MARGARET
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477510204
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7979 W. RIFLEMAN ST.
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-377-3850
Provider Business Mailing Address Fax Number:
208-369-9272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7979 W. RIFLEMAN ST.
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-377-3850
Provider Business Practice Location Address Fax Number:
208-369-9272
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XH1200X , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: OT456 , 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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