Healthcare Provider Details

I. General information

NPI: 1265524045
Provider Name (Legal Business Name): KOTH SPORTS PHYSICAL THERAPY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SADDLE ROAD
KETCHUM ID
83340-1510
US

IV. Provider business mailing address

PO BOX 1510
KETCHUM ID
83340-1510
US

V. Phone/Fax

Practice location:
  • Phone: 208-726-9222
  • Fax: 208-726-1607
Mailing address:
  • Phone: 208-788-3997
  • Fax: 208-726-1607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: SHERRI L KOTH
Title or Position: ITS SECRETARY/TREASURER, ITS BUS MG
Credential:
Phone: 208-788-3997