Healthcare Provider Details

I. General information

NPI: 1407123102
Provider Name (Legal Business Name): KIM KUTZNER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2011
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 N BOGUS BASIN RD
BOISE ID
83702-0902
US

IV. Provider business mailing address

11215 BODLEY DR
BOISE ID
83709-7740
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-0737
  • Fax: 208-344-0759
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2817
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: