Provider Demographics
NPI:1427103837
Name:IDAHO PHYSICAL THERAPY INC.
Entity type:Organization
Organization Name:IDAHO PHYSICAL THERAPY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:SHELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-314-5904
Mailing Address - Street 1:2005 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6311
Mailing Address - Country:US
Mailing Address - Phone:208-463-0022
Mailing Address - Fax:208-463-0031
Practice Address - Street 1:2005 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6311
Practice Address - Country:US
Practice Address - Phone:208-463-0022
Practice Address - Fax:208-463-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002689100Medicaid
ID1652146Medicare ID - Type UnspecifiedGROUP NUMBER