Healthcare Provider Details

I. General information

NPI: 1548429087
Provider Name (Legal Business Name): RYAN B HURST DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W FRANCIS ST
BLACKFOOT ID
83221-1751
US

IV. Provider business mailing address

285 W FRANCIS ST
BLACKFOOT ID
83221-1751
US

V. Phone/Fax

Practice location:
  • Phone: 208-965-5850
  • Fax: 208-782-1885
Mailing address:
  • Phone: 208-965-5850
  • Fax: 208-782-1885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2373
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: