Provider Demographics
NPI:1063092393
Name:TEATER, JAMES RICHARD (DPT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RICHARD
Last Name:TEATER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:952 N CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8603
Mailing Address - Country:US
Mailing Address - Phone:503-348-5132
Mailing Address - Fax:
Practice Address - Street 1:4300 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3138
Practice Address - Country:US
Practice Address - Phone:208-205-5059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4408225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist