Healthcare Provider Details

I. General information

NPI: 1285442442
Provider Name (Legal Business Name): SCOUT MOON-SHUN CAI DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/29/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8552 N GOVERNMENT WAY
HAYDEN ID
83835-9280
US

IV. Provider business mailing address

1233 N NORTHWOOD CENTER CT STE 101
COEUR D ALENE ID
83814-6190
US

V. Phone/Fax

Practice location:
  • Phone: 208-457-2450
  • Fax: 208-773-1473
Mailing address:
  • Phone: 208-215-2450
  • Fax: 208-773-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number8671936
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number8671936
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8671936
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: