Healthcare Provider Details

I. General information

NPI: 1467470658
Provider Name (Legal Business Name): FOOTHILLS PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 W MAIN ST SUITE 103
EVERSON WA
98247
US

IV. Provider business mailing address

PO BOX 702128
SALT LAKE CITY UT
84170-2128
US

V. Phone/Fax

Practice location:
  • Phone: 360-966-4810
  • Fax: 360-966-2884
Mailing address:
  • Phone: 801-708-7867
  • Fax: 801-677-1510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00009275
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. AMANDA CARNINE
Title or Position: OWNER
Credential: PT
Phone: 406-531-5918