Healthcare Provider Details

I. General information

NPI: 1982580452
Provider Name (Legal Business Name): POWER BASIN THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 11/14/2025
Certification Date: 11/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 E RIVERSIDE DR STE 200
EAGLE ID
83616-7473
US

IV. Provider business mailing address

101 W. CROOK STREET
MORECROFT WY
82721
US

V. Phone/Fax

Practice location:
  • Phone: 208-207-2726
  • Fax:
Mailing address:
  • Phone: 307-756-9200
  • Fax: 307-756-9203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: AMBER TUELLER
Title or Position: SECRETARY
Credential:
Phone: 208-207-2726