Healthcare Provider Details

I. General information

NPI: 1346205937
Provider Name (Legal Business Name): M ANDREW MIX RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 EASTLAND DR N
TWIN FALLS ID
83301-4458
US

IV. Provider business mailing address

276 EASTLAND DR N
TWIN FALLS ID
83301-4458
US

V. Phone/Fax

Practice location:
  • Phone: 208-735-8563
  • Fax: 208-735-8564
Mailing address:
  • Phone: 208-735-8563
  • Fax: 208-735-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1352
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: