Healthcare Provider Details

I. General information

NPI: 1619398393
Provider Name (Legal Business Name): CHAD SPENCER NEUBAUER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2013
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W STATE ST STE 270
EAGLE ID
83616-6974
US

IV. Provider business mailing address

1940 S BONITO WAY STE 190
MERIDIAN ID
83642-5618
US

V. Phone/Fax

Practice location:
  • Phone: 208-462-0808
  • Fax: 208-516-4488
Mailing address:
  • Phone: 208-287-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-6738
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: