=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215700067
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELCOME HOME H & W COACHING AND PELVIC HEALTH PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2023
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5073 E GERANIUM ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83716-7044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-982-9590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5073 E GERANIUM ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83716-7044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-982-9590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | KENNA BRINKMAN
-----------------------------------------------------
Credential | MPT
-----------------------------------------------------
Telephone | 208-982-9590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------