Healthcare Provider Details

I. General information

NPI: 1104979855
Provider Name (Legal Business Name): ANDREASEN PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 N 2190 E
SUGAR CITY ID
83448-1310
US

IV. Provider business mailing address

1808 N 2190 E
SUGAR CITY ID
83448-1310
US

V. Phone/Fax

Practice location:
  • Phone: 208-201-0877
  • Fax:
Mailing address:
  • Phone: 208-201-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-737
License Number StateID

VIII. Authorized Official

Name: MR. DIRK ANDREASEN
Title or Position: PRESIDENT
Credential: PT
Phone: 208-201-0877