Healthcare Provider Details

I. General information

NPI: 1609960947
Provider Name (Legal Business Name): BENJAMIN NATHANIEL SHATTO RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 W EMERALD ST
BOISE ID
83704-9015
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-0666
  • Fax: 208-375-2996
Mailing address:
  • Phone: 951-374-7288
  • Fax: 951-666-5099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1883
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: