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General NPI Number Information
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NPI Number | 1821491424
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Entity Type | Organization
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Legal Business Name | RENAISSANCE REHAB
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Dates
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Enumeration Date | 09/27/2014
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Last Update Date | 09/27/2014
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Provider Practice Location Address
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Address Line | 4846 WIND RIVER RD
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5828
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Country | US
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Telephone | 208-339-7234
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Fax | 208-552-0395
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Provider Business Mailing Address
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Address Line | 4846 WIND RIVER RD
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5828
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Country | US
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Telephone | 208-339-7234
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Fax | 208-552-0395
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Authorized Official
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Title or Position | OWNER
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Name | MR. JAMES A KING
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Credential | MS, OTR/L
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Telephone | 208-339-7234
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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-1398
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT-843
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License Number State | ID
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