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General NPI Number Information
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NPI Number | 1669530119
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Entity Type | Individual
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Provider Name | NICHOLAS P GREENWELL MPT
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Gender | Male
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 02/10/2016
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Provider Practice Location Address
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Address Line | 1263 BENNETT AVE SUITE 2
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City | BURLEY
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State | ID
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Zip | 83318-2666
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Country | US
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Telephone | 208-678-1191
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Fax | 208-678-1214
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Provider Business Mailing Address
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Address Line | 1263 BENNETT AVE STE 2
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City | BURLEY
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State | ID
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Zip | 83318-4906
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Country | US
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Telephone | 208-678-1191
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Fax |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-1359
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License Number State | ID
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