Healthcare Provider Details

I. General information

NPI: 1801846498
Provider Name (Legal Business Name): JANA NICOLE REPULSKI PT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 S RIVERSHORE LN SUITE 120
EAGLE ID
83616-4979
US

IV. Provider business mailing address

PO BOX 1328
EAGLE ID
83616-1328
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-8020
  • Fax: 208-938-8016
Mailing address:
  • Phone: 208-938-8020
  • Fax: 208-938-8016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT1158
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: