Healthcare Provider Details

I. General information

NPI: 1366701948
Provider Name (Legal Business Name): COLUMBUS CANDIES PT MPA/HA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 N WHITLEY DR STE 1A
FRUITLAND ID
83619-2180
US

IV. Provider business mailing address

401 W SLAUGHTER LN STE 300
AUSTIN TX
78748-1774
US

V. Phone/Fax

Practice location:
  • Phone: 208-452-0021
  • Fax: 208-452-0019
Mailing address:
  • Phone: 512-888-1201
  • Fax: 512-888-1202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1304798
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1689
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: