Healthcare Provider Details

I. General information

NPI: 1194349381
Provider Name (Legal Business Name): SAMUEL TAYLOR MULFORD PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 N STEELHEAD WAY STE 162
BOISE ID
83704-8388
US

IV. Provider business mailing address

1411 FALLS AVE E STE 401
TWIN FALLS ID
83301-3455
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-9747
  • Fax: 208-323-9752
Mailing address:
  • Phone: 82-969-9945
  • Fax: 208-944-0488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4271
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7621
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: