Healthcare Provider Details

I. General information

NPI: 1962488205
Provider Name (Legal Business Name): SCOTT R BLOXHAM P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 8TH ST STE A
RUPERT ID
83350-1527
US

IV. Provider business mailing address

545 CEDAR DR
BURLEY ID
83318-2821
US

V. Phone/Fax

Practice location:
  • Phone: 208-436-9016
  • Fax: 208-436-4922
Mailing address:
  • Phone: 208-878-9274
  • Fax: 208-436-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberRPT-085
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: