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General NPI Number Information
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NPI Number | 1326443607
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DEVELOPMENT CLINIC
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Dates
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Enumeration Date | 10/28/2014
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Last Update Date | 10/28/2014
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Provider Practice Location Address
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Address Line | 4846 WIND RIVER RD
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5828
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Country | US
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Telephone | 208-339-7234
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Fax | 208-552-0935
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Provider Business Mailing Address
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Address Line | PO BOX 365
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City | IONA
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State | ID
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Zip | 83427-0365
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Country | US
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Telephone | 208-339-7234
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Fax | 208-552-0395
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JAMES A KING
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Credential | MS, OTR/L
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Telephone | 208-339-7234
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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 | ID
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