1295339620 NPI number — FOUNDATIONS PEDIATRIC THERAPY PLLC

Table of content: (NPI 1295339620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295339620 NPI number — FOUNDATIONS PEDIATRIC THERAPY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNDATIONS PEDIATRIC THERAPY PLLC
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:
1295339620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11536 W PRISTINEBROOK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STAR
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83669-5784
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-654-6161
Provider Business Mailing Address Fax Number:
208-473-7320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 E 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIDDLETON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-654-6161
Provider Business Practice Location Address Fax Number:
208-473-7320
Provider Enumeration Date:
11/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
POLLOCK
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / THERAPIST
Authorized Official Telephone Number:
208-651-6161

Provider Taxonomy Codes

  • Taxonomy code: 225XF0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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