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General NPI Number Information
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NPI Number | 1194129817
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Entity Type | Organization
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Legal Business Name | I CAN PT LLC
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Dates
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Enumeration Date | 10/09/2014
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Last Update Date | 02/06/2015
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Provider Practice Location Address
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Address Line | 1626 WELLS AVE SUITE 105
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City | MERIDIAN
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State | ID
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Zip | 83642-4524
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Country | US
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Telephone | 208-789-0200
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Fax | 208-288-2784
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Provider Business Mailing Address
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Address Line | 1626 WELLS AVE SUITE 105
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City | MERIDIAN
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State | ID
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Zip | 83642-4524
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Country | US
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Telephone | 208-789-0200
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Fax | 208-288-2784
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Authorized Official
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Title or Position | CEO
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Name | MRS. HEATHER J HENDERSON
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Credential | DPT
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Telephone | 208-789-0200
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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-2550
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License Number State | ID
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