=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073697512
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRI-STATE S.P.O.R.T. PHYSICAL THERAPY CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 04/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1119 HIGHLAND AVE STE 2
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99403-2836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-758-9404
-----------------------------------------------------
Fax | 509-758-8267
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 328 WARNER DR STE 8
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501-4441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-746-7573
-----------------------------------------------------
Fax | 208-746-4519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | KELLY A STEIGER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 208-746-7573
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 06008772.0
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------