Provider Demographics
NPI:1154743912
Name:62 DEGREES PHYSICAL THERAPY
Entity type:Organization
Organization Name:62 DEGREES PHYSICAL THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATRIN
Authorized Official - Middle Name:HURLEY
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CWS, FACCWS
Authorized Official - Phone:208-321-7831
Mailing Address - Street 1:8660 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4825
Mailing Address - Country:US
Mailing Address - Phone:208-321-7831
Mailing Address - Fax:208-995-2870
Practice Address - Street 1:8660 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4825
Practice Address - Country:US
Practice Address - Phone:208-321-7831
Practice Address - Fax:208-995-2870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty