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General NPI Number Information
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NPI Number | 1306608104
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Entity Type | Organization
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Legal Business Name | IDAHO LUNG AND HEART
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Dates
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Enumeration Date | 01/26/2024
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 38 S 2ND E
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City | REXBURG
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State | ID
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Zip | 83440-2671
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Country | US
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Telephone | 801-616-7253
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Fax |
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Provider Business Mailing Address
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Address Line | 38 S 2ND E STE 2
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City | REXBURG
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State | ID
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Zip | 83440-2675
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Country | US
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Telephone | 801-616-7253
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRADLEY S CORDERO
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Credential |
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Telephone | 208-359-9570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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