Healthcare Provider Details

I. General information

NPI: 1306608104
Provider Name (Legal Business Name): IDAHO LUNG AND HEART
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 S 2ND E
REXBURG ID
83440-2671
US

IV. Provider business mailing address

38 S 2ND E STE 2
REXBURG ID
83440-2675
US

V. Phone/Fax

Practice location:
  • Phone: 801-616-7253
  • Fax:
Mailing address:
  • Phone: 801-616-7253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY S CORDERO
Title or Position: OWNER
Credential:
Phone: 208-359-9570