Healthcare Provider Details

I. General information

NPI: 1245766518
Provider Name (Legal Business Name): IDAHO SPINE AND SPORTS PHYSICAL THERAPY - SILVERSTONE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 S EAGLE RD
MERIDIAN ID
83642-2665
US

IV. Provider business mailing address

2316 S EAGLE RD
MERIDIAN ID
83642-2665
US

V. Phone/Fax

Practice location:
  • Phone: 208-286-2707
  • Fax: 208-286-2743
Mailing address:
  • Phone: 208-286-2707
  • Fax: 208-286-2743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2983
License Number StateID

VIII. Authorized Official

Name: ROBERT BRET ADAMS
Title or Position: OWNER/PARTNER
Credential: PT
Phone: 208-939-0533