Healthcare Provider Details

I. General information

NPI: 1093864282
Provider Name (Legal Business Name): TRI-CITY PHYSICAL THERAPY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N. WHITLEY DRIVE SUITE 1
FRUITLAND ID
83619-2706
US

IV. Provider business mailing address

215 N. WHITLEY DRIVE SUITE 1
FRUITLAND ID
83619-2706
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-6366
  • Fax: 208-452-6399
Mailing address:
  • Phone: 208-452-6366
  • Fax: 208-452-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberRPT550
License Number StateID

VIII. Authorized Official

Name: MR. CODY DEE STEPHENS
Title or Position: OWNER/PRESIDENT
Credential: P.T.
Phone: 208-452-6366