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General NPI Number Information
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NPI Number | 1063092393
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Entity Type | Individual
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Provider Name | JAMES RICHARD TEATER DPT
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Gender | Male
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Dates
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Enumeration Date | 04/12/2021
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Last Update Date | 04/12/2021
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Provider Practice Location Address
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Address Line | 4300 E FLAMINGO AVE
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City | NAMPA
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State | ID
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Zip | 83687-3138
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Country | US
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Telephone | 208-205-5059
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Fax |
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Provider Business Mailing Address
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Address Line | 952 N CAMELOT DR
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City | BOISE
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State | ID
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Zip | 83704-8603
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Country | US
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Telephone | 503-348-5132
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-4408
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License Number State | ID
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