Healthcare Provider Details

I. General information

NPI: 1548717895
Provider Name (Legal Business Name): MVMNT:GYM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2016
Last Update Date: 09/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S 3RD AVE
SANDPOINT ID
83864-1314
US

IV. Provider business mailing address

PO BOX 566
SANDPOINT ID
83864-0566
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: RYAN EGAN
Title or Position: CEO
Credential:
Phone: 208-263-9999