Healthcare Provider Details

I. General information

NPI: 1437744752
Provider Name (Legal Business Name): SCOTT RANDKLEV PHYSICAL THERAPY P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 E KATHLEEN AVE STE 500
COEUR D ALENE ID
83815-5238
US

IV. Provider business mailing address

1296 S FAIRMONT LOOP
COEUR D ALENE ID
83814-8932
US

V. Phone/Fax

Practice location:
  • Phone: 208-292-1372
  • Fax: 208-292-1374
Mailing address:
  • Phone: 208-431-0268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT RANDKLEV
Title or Position: PRESIDENT
Credential: DPT
Phone: 208-431-0268