Healthcare Provider Details

I. General information

NPI: 1497969604
Provider Name (Legal Business Name): IDAHO PHYSICAL MEDICINE & REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 ROBBINS RD
BOISE ID
83702-4539
US

IV. Provider business mailing address

600 N. ROBBINS RD
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-489-4016
  • Fax: 208-489-4015
Mailing address:
  • Phone: 208-489-4016
  • Fax: 208-489-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. SHARON A LEE
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-489-5160