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General NPI Number Information
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NPI Number | 1689770711
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Entity Type | Organization
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Legal Business Name | PRO MOTION PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 09/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1101 N 28TH ST
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City | BOISE
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State | ID
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Zip | 83702-2208
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Country | US
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Telephone | 208-336-1042
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Fax |
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Provider Business Mailing Address
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Address Line | 4725 SAMARA ST
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City | BOISE
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State | ID
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Zip | 83703-3642
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Country | US
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Telephone | 208-336-1042
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Fax |
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Authorized Official
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Title or Position | MEMBER / MANAGER
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Name | GAVIN MCEACHERN MORRISON
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Credential | PT
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Telephone | 208-336-1042
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | PT-1516
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License Number State | ID
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