Healthcare Provider Details

I. General information

NPI: 1609110964
Provider Name (Legal Business Name): KATHRYN ANN DARDIS P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/26/2012
Last Update Date: 11/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 FLOYDE ST
MCCALL ID
83638-4508
US

IV. Provider business mailing address

PO BOX 2789
MCCALL ID
83638-2789
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-2112
  • Fax:
Mailing address:
  • Phone: 208-634-4526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPT-440
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: