1033596747 NPI number — AUTUMN GROVE

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 1033596747 NPI number — AUTUMN GROVE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROVE
Provider First Name:
AUTUMN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1033596747
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8238 N GOVERNMENT WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835-5034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-762-2100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8238 N GOVERNMENT WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835-5034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-762-2100
Provider Business Practice Location Address Fax Number:
208-762-2101
Provider Enumeration Date:
05/01/2015

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: 2251X0800X , with the licence number:  PTL. 0013479 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT-5390 , 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)

  • Identifier: PT-5390 . This is a "IDAHO STATE PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: PTL. 0013479 . This is a "COLORADO STATE PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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