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General NPI Number Information
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NPI Number | 1568645554
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Entity Type | Organization
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Legal Business Name | PHYSICAL THERAPY AND SPORTS MEDICINE CLINIC INC
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Dates
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Enumeration Date | 12/12/2007
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Last Update Date | 09/15/2008
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Provider Practice Location Address
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Address Line | 4102 E 82 N
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City | RIGBY
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State | ID
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Zip | 83442-5894
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Country | US
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Telephone | 208-745-8580
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Fax | 208-745-8580
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Provider Business Mailing Address
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Address Line | 4102 E 82 N
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City | RIGBY
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State | ID
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Zip | 83442-5894
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Country | US
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Telephone | 208-745-8580
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Fax | 208-745-8580
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Authorized Official
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Title or Position | SECRETARY
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Name | MS. LAURA B JENKINS
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Credential |
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Telephone | 208-745-8580
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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 | T 236
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License Number State | ID
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