Provider Demographics
NPI:1427147784
Name:BENEDETTI, C RIC (DPT)
Entity type:Individual
Prefix:
First Name:C
Middle Name:RIC
Last Name:BENEDETTI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:C. RIC
Other - Middle Name:
Other - Last Name:BENEDETTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT, MBA
Mailing Address - Street 1:PO BOX 2844
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2844
Mailing Address - Country:US
Mailing Address - Phone:208-233-4800
Mailing Address - Fax:208-233-4887
Practice Address - Street 1:1033 W QUINN RD
Practice Address - Street 2:560 MEMORIAL DR
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-2425
Practice Address - Country:US
Practice Address - Phone:208-233-4800
Practice Address - Fax:208-233-4887
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT131225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID650009795OtherRAILROAD MEDICARE
IDT1542OtherBLUE CROSS
ID000010008588OtherBLUE SHIELD
ID004396600Medicaid
ID650009795OtherRAILROAD MEDICARE