Healthcare Provider Details

I. General information

NPI: 1891675898
Provider Name (Legal Business Name): MICHAEL ANGELO RUVALCABA I DPT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 10/24/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E PINE ST
CALDWELL ID
83605-4836
US

IV. Provider business mailing address

11888 LOON ST
CALDWELL ID
83605-8133
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-5142
  • Fax:
Mailing address:
  • Phone: 208-454-5142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5771146
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: