Healthcare Provider Details

I. General information

NPI: 1386023026
Provider Name (Legal Business Name): JIM THOMAS CRITTENDEN OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 E 17TH ST STE A
IDAHO FALLS ID
83404-6375
US

IV. Provider business mailing address

1740 E 17TH ST STE A
IDAHO FALLS ID
83404-6375
US

V. Phone/Fax

Practice location:
  • Phone: 208-346-7500
  • Fax:
Mailing address:
  • Phone: 208-346-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-591
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: