Healthcare Provider Details

I. General information

NPI: 1962518548
Provider Name (Legal Business Name): TREVOR JOSEPH ECCLES PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E PARKCENTER BLVD SUITE 114 TAI - BOISE PHYSICAL THERAPY - PARKCENTER
BOISE ID
83706-6505
US

IV. Provider business mailing address

11481 SW HALL BLVD STE 201 THERAPEUTIC ASSOCIATES INC
PORTLAND OR
97223-8403
US

V. Phone/Fax

Practice location:
  • Phone: 208-433-9211
  • Fax: 208-433-9241
Mailing address:
  • Phone: 800-219-8835
  • Fax: 503-443-1402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1990
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: