1093864282 NPI number — TRI-CITY PHYSICAL THERAPY, P.C.

Table of content: (NPI 1093864282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093864282 NPI number — TRI-CITY PHYSICAL THERAPY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-CITY PHYSICAL THERAPY, P.C.
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:
6
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:
1093864282
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 N. WHITLEY DRIVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
FRUITLAND
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83619-2706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-452-6366
Provider Business Mailing Address Fax Number:
208-452-6399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 N. WHITLEY DRIVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FRUITLAND
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83619-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-452-6366
Provider Business Practice Location Address Fax Number:
208-452-6399
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHENS
Authorized Official First Name:
CODY
Authorized Official Middle Name:
DEE
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
208-452-6366

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: RPT550 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 806639200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com