Healthcare Provider Details

I. General information

NPI: 1174051429
Provider Name (Legal Business Name): IAN CAMPBELL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2195 W HILL RD
BOISE ID
83702-0622
US

IV. Provider business mailing address

2195 W HILL RD
BOISE ID
83702-0622
US

V. Phone/Fax

Practice location:
  • Phone: 208-850-6995
  • Fax: 208-323-9752
Mailing address:
  • Phone: 208-850-6995
  • Fax: 208-323-9752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-5047
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: