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General NPI Number Information
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NPI Number | 1831181106
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Entity Type | Organization
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Legal Business Name | PHYSICAL THERAPY SPORTS & REHAB
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Dates
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Enumeration Date | 08/22/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 540 S GARFIELD AVE
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City | POCATELLO
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State | ID
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Zip | 83204-3333
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Country | US
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Telephone | 208-232-2740
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Fax |
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Provider Business Mailing Address
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Address Line | 540 S GARFIELD AVE
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City | POCATELLO
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State | ID
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Zip | 83204-3333
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Country | US
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Telephone | 208-232-2740
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Fax | 208-232-7746
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Authorized Official
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Title or Position | OWNER
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Name | ALLEN B MARTIN
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Credential | PPT
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Telephone | 208-232-2740
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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 | RPT195
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | RPT004
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License Number State | ID
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