Provider Demographics
NPI:1326443607
Name:PEDIATRIC DEVELOPMENT CLINIC
Entity type:Organization
Organization Name:PEDIATRIC DEVELOPMENT CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L
Authorized Official - Phone:208-339-7234
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-0365
Mailing Address - Country:US
Mailing Address - Phone:208-339-7234
Mailing Address - Fax:208-552-0395
Practice Address - Street 1:4846 WIND RIVER RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5828
Practice Address - Country:US
Practice Address - Phone:208-339-7234
Practice Address - Fax:208-552-0935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy