Provider Demographics
NPI: | 1992690101 |
---|---|
Name: | HOMEGROWN PEDIATRIC THERAPIES LLC |
Entity type: | Organization |
Organization Name: | HOMEGROWN PEDIATRIC THERAPIES LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER, PHYSICAL THERAPIST |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ROSS |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GARDNER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | PT, DPT |
Authorized Official - Phone: | 208-613-7361 |
Mailing Address - Street 1: | 8000 S 55TH W |
Mailing Address - Street 2: | |
Mailing Address - City: | IDAHO FALLS |
Mailing Address - State: | ID |
Mailing Address - Zip Code: | 83402-5733 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 208-613-7361 |
Mailing Address - Fax: | 843-892-8444 |
Practice Address - Street 1: | 8000 S 55TH W |
Practice Address - Street 2: | |
Practice Address - City: | IDAHO FALLS |
Practice Address - State: | ID |
Practice Address - Zip Code: | 83402-5733 |
Practice Address - Country: | US |
Practice Address - Phone: | 208-613-7361 |
Practice Address - Fax: | 843-892-8444 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | HOMEGROWN PEDIATRIC THERAPIES LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2025-06-09 |
Last Update Date: | 2025-06-24 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
No | 224Z00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | Group - Multi-Specialty | |
No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
No | 225200000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | Group - Multi-Specialty | |
No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
No | 2355S0801X | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | Group - Multi-Specialty |
No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |