Provider Demographics
NPI:1306064910
Name:CHANNING PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:CHANNING PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-8005
Mailing Address - Street 1:2570 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7515
Mailing Address - Country:US
Mailing Address - Phone:208-529-8005
Mailing Address - Fax:
Practice Address - Street 1:2570 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7515
Practice Address - Country:US
Practice Address - Phone:208-529-8005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-22
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805633700Medicaid
IDT-097-3OtherBC OF IDAHO GROUP ID#
ID39012OtherBS OF IDAHO GROUP ID#
IDT-097-3OtherBC OF IDAHO GROUP ID#