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NPI Code Detail

MEDICARE: PRESTON CHARLES MARTIN MPT

MEDICARE: PRESTON CHARLES MARTIN MPT
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
1225100000XPhysical TherapistPT-1824ID

General Provider Information

NPI Number : 1912167230
Entity Type Code : Individual
Provider Name (Legal Business Name) : PRESTON CHARLES MARTIN MPT
Provider Business Mailing Address
First Line : 5927 S TALLOWTREE WAY
Second Line :
City : BOISE
State : ID
Zip : 83716-6965
Country : US
Telephone Number : 208-859-1114
Fax Number :
Provider Business Practice Location Address
First Line : 1001 S HILTON ST
Second Line :
City : BOISE
State : ID
Zip : 83705-1925
Country : US
Telephone Number : 208-345-4464
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/10/2008
Last Update Date : 06/10/2008

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Directions to “ PRESTON CHARLES MARTIN MPT” Practice Location

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