MEDICARE: FOOTHILLS REHABILITATION & PERFORMANCE SERVICES

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	261QP2000X	Physical Therapy Clinic/Center		ID

General Provider Information

NPI Number	:	1831211093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTHILLS REHABILITATION & PERFORMANCE SERVICES

Provider Business Mailing Address
First Line	:	3814 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7591
Country	:	US
Telephone Number	:	208-529-3562
Fax Number	:	208-529-4064

Provider Business Practice Location Address
First Line	:	3814 WASHINGTON PKWY
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7591
Country	:	US
Telephone Number	:	208-529-3562
Fax Number	:	208-529-4064

Authorized Official
Title or Position	:	OWNER
Name	:	BRENT SHELDON KENNEDY
Credential	:	DPT
Telephone Number	:	208-529-3562

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	06/02/2008

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