Healthcare Provider Details

I. General information

NPI: 1336315175
Provider Name (Legal Business Name): PROACTIVE PHYSICAL THERAPY OF MCCALL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 N COUNCIL AVENUE SUITE A
COUNCIL ID
83612-0000
US

IV. Provider business mailing address

PO BOX 2041
MCCALL ID
83638-2041
US

V. Phone/Fax

Practice location:
  • Phone: 208-253-6893
  • Fax:
Mailing address:
  • Phone: 208-634-8517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MOIRA J STOTLER
Title or Position: BILLING SPECIALIST
Credential:
Phone: 208-634-8517