Provider Demographics
NPI:1194129817
Name:I CAN PT LLC
Entity type:Organization
Organization Name:I CAN PT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-789-0200
Mailing Address - Street 1:1626 WELLS AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4524
Mailing Address - Country:US
Mailing Address - Phone:208-789-0200
Mailing Address - Fax:208-288-2784
Practice Address - Street 1:1626 WELLS AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-4524
Practice Address - Country:US
Practice Address - Phone:208-789-0200
Practice Address - Fax:208-288-2784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1194129817OtherGROUP NPI
ID20006237Medicare UPIN