Healthcare Provider Details

I. General information

NPI: 1669530051
Provider Name (Legal Business Name): BURLEY PHYSICAL THERAPY AND REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1263 BENNETT AVE SUITE 2
BURLEY ID
83318-4906
US

IV. Provider business mailing address

1263 BENNETT AVE SUITE 2
BURLEY ID
83318-4906
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-1191
  • Fax: 208-678-1214
Mailing address:
  • Phone: 208-678-1191
  • Fax: 208-678-1214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateID

VIII. Authorized Official

Name: MRS. STACY GREENWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-678-1191