Provider Demographics
NPI:1992975825
Name:SPINE AND SPORT PYSICAL THERAPY PC
Entity type:Organization
Organization Name:SPINE AND SPORT PYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:RAWLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-359-6127
Mailing Address - Street 1:217 N 2ND EAST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2057
Mailing Address - Country:US
Mailing Address - Phone:208-359-6127
Mailing Address - Fax:208-359-9479
Practice Address - Street 1:217 N 2ND EAST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1621
Practice Address - Country:US
Practice Address - Phone:208-359-6127
Practice Address - Fax:208-359-9479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1346225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
650015362OtherRAILROAD MEDICARE
ID000010020600OtherREGENCE BLUE SHIELD
WY1210564Medicaid
IDT3860OtherBLUE CROSS
185556100OtherUS DEPARTMENT OF LABOR
ID805399800Medicaid
ID805399800Medicaid