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General NPI Number Information
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NPI Number | 1033359450
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Entity Type | Organization
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Legal Business Name | GRIDIRON REHAB AND ATHLETIC FITNESS, LLC
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Dates
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Enumeration Date | 02/25/2009
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Last Update Date | 05/17/2018
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Provider Practice Location Address
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Address Line | 3035 W MCMILLAN RD SUITE 104
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City | MERIDIAN
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State | ID
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Zip | 83646
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Country | US
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Telephone | 208-887-8684
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Fax | 208-887-9226
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Provider Business Mailing Address
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Address Line | 3035 W MCMILLAN RD SUITE 104
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City | MERIDIAN
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State | ID
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Zip | 83646-6163
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Country | US
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Telephone | 208-887-8684
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Fax | 208-887-9226
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Authorized Official
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Title or Position | ADMINISTRATOR / MANAGING EMPLOYEE
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Name | ERIC TAMURA
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Credential |
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Telephone | 208-887-8684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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