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General NPI Number Information
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NPI Number | 1366701948
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Entity Type | Individual
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Provider Name | COLUMBUS CANDIES PT MPA/HA PH.D.
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Gender | Male
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Dates
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Enumeration Date | 05/16/2012
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Last Update Date | 10/09/2018
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Provider Practice Location Address
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Address Line | 1611 N WHITLEY DR STE 1A
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City | FRUITLAND
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State | ID
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Zip | 83619-2180
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Country | US
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Telephone | 208-452-0021
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Fax | 208-452-0019
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Provider Business Mailing Address
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Address Line | 401 W SLAUGHTER LN STE 300
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City | AUSTIN
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State | TX
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Zip | 78748-1774
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Country | US
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Telephone | 512-888-1201
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Fax | 512-888-1202
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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 | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 1304798
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License Number State | TX
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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 | PT-1689
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License Number State | ID
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