Healthcare Provider Details

I. General information

NPI: 1720756190
Provider Name (Legal Business Name): S.P.O.R.T. PHYSICAL THERAPY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 WARNER DR STE 8
LEWISTON ID
83501-4441
US

IV. Provider business mailing address

328 WARNER DR STE 8
LEWISTON ID
83501-4441
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-7573
  • Fax:
Mailing address:
  • Phone: 208-746-7573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: KELLY ANDREW STEIGER
Title or Position: OWNER
Credential:
Phone: 208-746-7573