Provider Demographics
NPI:1194349381
Name:MULFORD, SAMUEL TAYLOR (PT, DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:TAYLOR
Last Name:MULFORD
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:082-969-9945
Mailing Address - Fax:208-944-0488
Practice Address - Street 1:554 N STEELHEAD WAY STE 162
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8388
Practice Address - Country:US
Practice Address - Phone:208-323-9747
Practice Address - Fax:208-323-9752
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4271225100000X
ID7621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist