Provider Demographics
NPI:1063812717
Name:REDE, SETH (LAT, ATC)
Entity type:Individual
Prefix:
First Name:SETH
Middle Name:
Last Name:REDE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83725-1021
Mailing Address - Country:US
Mailing Address - Phone:208-426-1696
Mailing Address - Fax:208-426-2603
Practice Address - Street 1:1910 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83725-1021
Practice Address - Country:US
Practice Address - Phone:208-426-1696
Practice Address - Fax:208-426-2603
Is Sole Proprietor?:No
Enumeration Date:2014-08-31
Last Update Date:2014-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-5192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer