=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003863457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTION THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1175 E PARKCENTER BLVD STE 101
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-6751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-367-1010
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3090 E GENTRY WAY STE 250
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-888-0044
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID S RAY
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 208-888-0044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------