=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104226828
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE THERAPY SOLUTIONS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2014
-----------------------------------------------------
Last Update Date | 11/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13900 W WAINWRIGHT DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83713-5028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-351-9955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11106 WEST SPRINGGOLD DRIVE
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-351-9955
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | JONATHAN ROY GARDUNIA
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 208-351-9955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | PT2549
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------