Healthcare Provider Details

I. General information

NPI: 1366799827
Provider Name (Legal Business Name): PHYSICAL THERAPY CLINIC,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 SHOUP STREET
SALMON ID
83467
US

IV. Provider business mailing address

PO BOX 1107
SALMON ID
83467-1107
US

V. Phone/Fax

Practice location:
  • Phone: 208-756-2005
  • Fax: 208-756-4020
Mailing address:
  • Phone: 208-756-2005
  • Fax: 208-756-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT 92
License Number StateID

VIII. Authorized Official

Name: ZHOHNANN THAYN
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: P.T.
Phone: 208-756-2005