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General NPI Number Information
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NPI Number | 1427072982
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Entity Type | Organization
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Legal Business Name | ADVANCED PERFORMANCE PHYSICAL THERAPY PLLC
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Dates
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Enumeration Date | 07/27/2006
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Last Update Date | 01/30/2017
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Provider Practice Location Address
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Address Line | 333 N 18TH AVE STE D-2
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City | POCATELLO
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State | ID
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Zip | 83201-3358
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Country | US
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Telephone | 208-232-6490
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Fax | 208-234-4805
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Provider Business Mailing Address
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Address Line | 333 N 18TH AVE STE D-2
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City | POCATELLO
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State | ID
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Zip | 83201-3358
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Country | US
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Telephone | 208-232-6490
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Fax | 208-234-4805
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROBERT LANCE MARSHALL
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Credential | PT, DPT, MS
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Telephone | 208-232-6490
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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 | PT1003
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License Number State | ID
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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 | PT1535
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License Number State | ID
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