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General NPI Number Information
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NPI Number | 1245619576
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Entity Type | Individual
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Provider Name | TRISTAN KING
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Gender | Male
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Dates
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Enumeration Date | 05/19/2015
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Last Update Date | 05/19/2015
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Provider Practice Location Address
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Address Line | 3360 S 15TH E
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8321
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Country | US
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Telephone | 208-552-6200
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Fax |
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Provider Business Mailing Address
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Address Line | 3261 N 3250 W
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City | MOORE
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State | ID
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Zip | 83255-8729
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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-3955
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License Number State | ID
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