=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730104597
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA E. HERNANDEZ P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1224 8TH ST SUITE A
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83350-1527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-436-9016
-----------------------------------------------------
Fax | 208-436-4922
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 E 100 S
-----------------------------------------------------
City | RUPERT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83350-9728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-436-0574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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-768
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------