Provider Demographics
NPI:1962424952
Name:CLIFFORD L KIRACOFE PT PA
Entity type:Organization
Organization Name:CLIFFORD L KIRACOFE PT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRACOFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-772-6991
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1579225100000X
MT1620225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807136100Medicaid
ID1377934Medicare ID - Type Unspecified