Healthcare Provider Details

I. General information

NPI: 1184972184
Provider Name (Legal Business Name): PERIWINKLE CHILDREN'S THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2012
Last Update Date: 08/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W BIZZTOWN LOOP
HAYDEN ID
83835-5113
US

IV. Provider business mailing address

1401 W BIZZTOWN LOOP
HAYDEN ID
83835-5113
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-3502
  • Fax: 888-310-4824
Mailing address:
  • Phone: 208-762-3502
  • Fax: 888-310-4824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHRISTY ADAMS
Title or Position: CO-OWNER
Credential:
Phone: 208-762-3502