MEDICARE: CHANNING PHYSICAL THERAPY PC

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	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	T-097-3	OTHER	ID	BC OF IDAHO GROUP ID#
3	39012	OTHER	ID	BS OF IDAHO GROUP ID#

General Provider Information

NPI Number	:	1306064910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHANNING PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	2570 CHANNING WAY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7515
Country	:	US
Telephone Number	:	208-529-8005
Fax Number	:

Provider Business Practice Location Address
First Line	:	2570 CHANNING WAY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7515
Country	:	US
Telephone Number	:	208-529-8005
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MS. MEISHA ADAMS
Credential	:
Telephone Number	:	208-529-8005

Provider Enumeration Date	:	04/22/2007
Last Update Date	:	06/21/2018

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