Healthcare Provider Details

I. General information

NPI: 1902182298
Provider Name (Legal Business Name): FUNCTIONAL PHYSICAL THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8950 W EMERALD ST SUITE 195
BOISE ID
83704-4854
US

IV. Provider business mailing address

8950 W EMERALD ST SUITE 195
BOISE ID
83704-4854
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-7313
  • Fax: 208-376-7487
Mailing address:
  • Phone: 208-376-7313
  • Fax: 208-376-7487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT670
License Number StateID

VIII. Authorized Official

Name: RAJCOOMAR ISSUREE
Title or Position: PHYSICAL THERAPIST/DIRECTOR
Credential: P.T.
Phone: 208-376-7313