Provider Demographics
NPI:1306462197
Name:TWO RIVERS MYOFUNCTIONAL THERAPY LLC
Entity type:Organization
Organization Name:TWO RIVERS MYOFUNCTIONAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MYOFUCNTIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-918-1953
Mailing Address - Street 1:635 W CEDAR POINTE WAY
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5582
Mailing Address - Country:US
Mailing Address - Phone:208-918-1953
Mailing Address - Fax:
Practice Address - Street 1:635 W CEDAR POINTE WAY
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5582
Practice Address - Country:US
Practice Address - Phone:208-918-1953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty