Healthcare Provider Details

I. General information

NPI: 1801812482
Provider Name (Legal Business Name): IRONWOOD DRIVE PHYSICAL THERAPY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 NORTHWEST BLVD STE 106
COEUR D ALENE ID
83814-5605
US

IV. Provider business mailing address

1450 NORTHWEST BLVD STE 106
COEUR D ALENE ID
83814-5605
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-6264
  • Fax: 208-664-4313
Mailing address:
  • Phone: 208-667-6264
  • Fax: 208-664-4313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DIRK ANTHONY BAIRD
Title or Position: OWNER
Credential: DPT
Phone: 208-667-6264