Provider Demographics
NPI:1154162113
Name:WILD ROSE PHYSIO PLLC
Entity type:Organization
Organization Name:WILD ROSE PHYSIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENTGES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:206-948-7475
Mailing Address - Street 1:PO BOX 51
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:ID
Mailing Address - Zip Code:83871-0051
Mailing Address - Country:US
Mailing Address - Phone:206-948-7475
Mailing Address - Fax:208-242-4018
Practice Address - Street 1:325 W PALOUSE RIVER DR
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-8956
Practice Address - Country:US
Practice Address - Phone:208-689-6044
Practice Address - Fax:208-242-4018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy