Healthcare Provider Details

I. General information

NPI: 1033726880
Provider Name (Legal Business Name): MOSCOW PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 ALTURAS DRIVE SUITE 2
MOSCOW ID
83843
US

IV. Provider business mailing address

1174 ALTURAS DRIVE SUITE 2
MOSCOW ID
83843
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-0666
  • Fax: 208-375-2996
Mailing address:
  • Phone: 208-375-0666
  • Fax: 208-375-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHELLIE M MCCARTHY
Title or Position: VICE PRESIDENT
Credential:
Phone: 208-314-5904