=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154743912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 62 DEGREES PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2014
-----------------------------------------------------
Last Update Date | 01/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8660 W EMERALD ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-4825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-321-7831
-----------------------------------------------------
Fax | 208-995-2870
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8660 W EMERALD ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-4825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-321-7831
-----------------------------------------------------
Fax | 208-995-2870
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MEMBER
-----------------------------------------------------
Name | DR. KATRIN HURLEY MOFFETT
-----------------------------------------------------
Credential | PT, DPT, CWS, FACCWS
-----------------------------------------------------
Telephone | 208-321-7831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT632
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------