Healthcare Provider Details

I. General information

NPI: 1467010272
Provider Name (Legal Business Name): HEIDI COILLOT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/05/2019
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-6257
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: