Provider Demographics
NPI:1427073212
Name:KIRACOFE, CLIFFORD (RPT)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:
Last Name:KIRACOFE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 293
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-0293
Mailing Address - Country:US
Mailing Address - Phone:208-772-6991
Mailing Address - Fax:208-772-6674
Practice Address - Street 1:8836 N HESS ST
Practice Address - Street 2:STE C
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8718
Practice Address - Country:US
Practice Address - Phone:208-772-6991
Practice Address - Fax:208-772-6674
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1654300Medicare PIN