=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558607861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY KAY HAUSLADEN FOLEY PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2012
-----------------------------------------------------
Last Update Date | 12/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HOSPITAL DRIVE SUITE 104
-----------------------------------------------------
City | KETCHUM
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-727-8253
-----------------------------------------------------
Fax | 208-727-8258
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 100
-----------------------------------------------------
City | KETCHUM
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83340-0100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-727-8253
-----------------------------------------------------
Fax | 208-727-8258
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT-1726
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------