Healthcare Provider Details

I. General information

NPI: 1063829836
Provider Name (Legal Business Name): FOOTHILLS REHABILITATION & PERFORMANCE SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2014
Last Update Date: 09/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 WOODKING DR
IDAHO FALLS ID
83404-4720
US

IV. Provider business mailing address

3715 WOODKING DR
IDAHO FALLS ID
83404-4720
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-2255
  • Fax: 208-529-2022
Mailing address:
  • Phone: 208-529-2255
  • Fax: 208-529-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1740
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: BRENT KENNEDY
Title or Position: OWNER/MANAGER
Credential: DPT
Phone: 208-529-2255