MEDICARE: JONATHAN HOELZEN DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT-6196	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT-6196	OTHER	ID	BUREAU OF OCCUPATIONAL LICENSES

General Provider Information

NPI Number	:	1053877118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN HOELZEN DPT

Provider Business Mailing Address
First Line	:	1450 NORTHWEST BLVD STE 106
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83814-5605
Country	:	US
Telephone Number	:	208-667-6264
Fax Number	:	208-664-4313

Provider Business Practice Location Address
First Line	:	1088 W PRAIRIE AVE
Second Line	:
City	:	COEUR D ALENE
State	:	ID
Zip	:	83815-8741
Country	:	US
Telephone Number	:	208-772-6609
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2019
Last Update Date	:	03/10/2020

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