1851016356 NPI number — 208 PHYSICAL THERAPY LLC

Table of content: (NPI 1851016356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851016356 NPI number — 208 PHYSICAL THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
208 PHYSICAL THERAPY LLC
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:
1851016356
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 S BONITO WAY STE 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-5618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-287-9420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 STOCKS AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REXBURG
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83440-3590
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-261-2123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2022

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
TYREL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-201-0365

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1477045581 . This is a "MEDICARE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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