Healthcare Provider Details

I. General information

NPI: 1730756917
Provider Name (Legal Business Name): CAROLINE BRINSON BUSH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 S BROADWAY AVE
BOISE ID
83706-3600
US

IV. Provider business mailing address

6243 S WAYLAND WAY
MERIDIAN ID
83642-5711
US

V. Phone/Fax

Practice location:
  • Phone: 208-433-9211
  • Fax:
Mailing address:
  • Phone: 901-786-2761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-7147
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: