Healthcare Provider Details

I. General information

NPI: 1821077223
Provider Name (Legal Business Name): SYDNEY LYN PRAEGER RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 W 1ST ST #101
KETCHUM ID
83340
US

IV. Provider business mailing address

PO BOX 2182 180 W 1ST ST #101
KETCHUM ID
83340-2182
US

V. Phone/Fax

Practice location:
  • Phone: 208-725-5185
  • Fax: 208-725-5192
Mailing address:
  • Phone: 208-725-5185
  • Fax: 208-725-5192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberRPT316
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: