=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194510867
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALOUSE PELVIC REHABILITATION & PHYSICAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2025
-----------------------------------------------------
Last Update Date | 04/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1944 CRESTVIEW DR
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-9657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-553-9397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1944 CRESTVIEW DR
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-9657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-553-9397
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | KIMBERLY FLETCHER
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 509-553-9397
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------