Provider Demographics
NPI:1063951168
Name:KEYSTONE THERAPY
Entity type:Organization
Organization Name:KEYSTONE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:208-514-0670
Mailing Address - Street 1:1159 E IRON EAGLE DR
Mailing Address - Street 2:SUITE 170D
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6871
Mailing Address - Country:US
Mailing Address - Phone:208-514-0670
Mailing Address - Fax:208-549-7880
Practice Address - Street 1:1159 E IRON EAGLE DR
Practice Address - Street 2:SUITE 170D
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6871
Practice Address - Country:US
Practice Address - Phone:208-514-0670
Practice Address - Fax:208-549-7880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy