Healthcare Provider Details

I. General information

NPI: 1801944400
Provider Name (Legal Business Name): CENTER FOR ORTHOPEDIC REHABILITATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 S 5TH AVE STE 140
POCATELLO ID
83201-6410
US

IV. Provider business mailing address

275 S 5TH AVE STE 140
POCATELLO ID
83201-6410
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-4267
  • Fax: 208-232-4268
Mailing address:
  • Phone: 208-232-4267
  • Fax: 208-232-4268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-2487
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1730
License Number StateID

VIII. Authorized Official

Name: JOHN T BATES
Title or Position: PRESIDENT
Credential: MPT
Phone: 208-232-4267