Healthcare Provider Details

I. General information

NPI: 1205920899
Provider Name (Legal Business Name): WINWARD PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SOUTH 100 WEST STE A WINWARD PHYSICAL THERAPY
PRESTON ID
83263-1244
US

IV. Provider business mailing address

10 SOUTH 100 WEST STE A WINWARD PHYSICAL THERAPY
PRESTON ID
83263-1244
US

V. Phone/Fax

Practice location:
  • Phone: 208-852-0116
  • Fax: 208-852-0116
Mailing address:
  • Phone: 208-852-0116
  • Fax: 208-852-0116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT-1083
License Number StateID

VIII. Authorized Official

Name: DOUGLAS WINWARD
Title or Position: PRESIDENT
Credential: MPT
Phone: 208-852-0116