Healthcare Provider Details

I. General information

NPI: 1992975825
Provider Name (Legal Business Name): SPINE AND SPORT PYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N 2ND EAST
REXBURG ID
83440-1621
US

IV. Provider business mailing address

217 N 2ND EAST
REXBURG ID
83440-2057
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-6127
  • Fax: 208-359-9479
Mailing address:
  • Phone: 208-359-6127
  • Fax: 208-359-9479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1346
License Number StateID

VIII. Authorized Official

Name: JODY BOYD RAWLINGS
Title or Position: PHYSICAL THERAPIST
Credential: P.T.
Phone: 208-359-6127