Healthcare Provider Details

I. General information

NPI: 1104672682
Provider Name (Legal Business Name): PRIMARY THERAPY SOURCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 RIVER VISTA PL
TWIN FALLS ID
83301-3006
US

IV. Provider business mailing address

254 RIVER VISTA PL
TWIN FALLS ID
83301-3006
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-7333
  • Fax: 208-734-8350
Mailing address:
  • Phone: 208-734-7333
  • Fax: 208-734-8350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH JAN YINGST
Title or Position: MANAGING MEMBER
Credential: PT
Phone: 208-734-7333