1962518548 NPI number — TREVOR JOSEPH ECCLES PHYSICAL THERAPIST

Table of content: TREVOR JOSEPH ECCLES PHYSICAL THERAPIST (NPI 1962518548)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962518548 NPI number — TREVOR JOSEPH ECCLES PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ECCLES
Provider First Name:
TREVOR
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

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:
1962518548
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11481 SW HALL BLVD
Provider Second Line Business Mailing Address:
STE 201 THERAPEUTIC ASSOCIATES INC
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-443-1402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
415 E PARKCENTER BLVD
Provider Second Line Business Practice Location Address:
SUITE 114 TAI - BOISE PHYSICAL THERAPY - PARKCENTER
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83706-6505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-433-9211
Provider Business Practice Location Address Fax Number:
208-433-9241
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT1990 , 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)





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