=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508647900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CURRENT PHYSICAL THERAPY MERIDIAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2023
-----------------------------------------------------
Last Update Date | 10/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 N. HICKORY AVE UNIT 3 STE 115
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-314-4988
-----------------------------------------------------
Fax | 208-296-7921
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 S. VALLEY DR. STE A #178
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-800-1619
-----------------------------------------------------
Fax | 208-296-7921
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | NICHOLAS COLE HARTLEY
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 541-212-0337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------