Healthcare Provider Details

I. General information

NPI: 1851016356
Provider Name (Legal Business Name): 208 PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 STOCKS AVE STE C
REXBURG ID
83440-3590
US

IV. Provider business mailing address

1940 S BONITO WAY STE 190
MERIDIAN ID
83642-5618
US

V. Phone/Fax

Practice location:
  • Phone: 208-261-2123
  • Fax:
Mailing address:
  • Phone: 208-287-9420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: TYREL NELSON
Title or Position: OWNER
Credential: PT, DPT
Phone: 208-201-0365