1073697512 NPI number — TRI-STATE S.P.O.R.T. PHYSICAL THERAPY CLINIC

Table of content: (NPI 1073697512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073697512 NPI number — TRI-STATE S.P.O.R.T. PHYSICAL THERAPY CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STATE S.P.O.R.T. PHYSICAL THERAPY CLINIC
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:
1073697512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 WARNER DR
Provider Second Line Business Mailing Address:
STE 8
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501-4441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-746-7573
Provider Business Mailing Address Fax Number:
208-746-4519

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1119 HIGHLAND AVE
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-9404
Provider Business Practice Location Address Fax Number:
509-758-8267
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEIGER
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
208-746-7573

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  06008772.0 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7093479 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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