Healthcare Provider Details

I. General information

NPI: 1497948509
Provider Name (Legal Business Name): MCDONALD REHAB, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 FLANDRO DR SUITE 190
POCATELLO ID
83202-4940
US

IV. Provider business mailing address

1800 FLANDRO DR SUITE 190
POCATELLO ID
83202-4940
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2248
  • Fax: 208-233-0219
Mailing address:
  • Phone: 208-233-2248
  • Fax: 208-233-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1555
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT-884
License Number StateID

VIII. Authorized Official

Name: MR. BART W MCDONALD
Title or Position: OWNER
Credential: MPT
Phone: 208-233-2248