1184707911 NPI number — POCATELLO PHYSICAL THERAPY CLINIC PA

Table of content: (NPI 1184707911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184707911 NPI number — POCATELLO PHYSICAL THERAPY CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POCATELLO PHYSICAL THERAPY CLINIC 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:
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:
1184707911
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2844
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83206-2844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-233-4800
Provider Business Mailing Address Fax Number:
208-233-4887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1033 W QUINN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83202-2425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-233-4800
Provider Business Practice Location Address Fax Number:
208-233-4887
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DES FOSSES
Authorized Official First Name:
DAN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT OWNER
Authorized Official Telephone Number:
208-233-4800

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , 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: 002463600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010026861 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: T0296 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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