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General NPI Number Information
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NPI Number | 1831949288
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Entity Type | Organization
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Legal Business Name | BOUNCE BACK OT LLC
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Dates
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Enumeration Date | 03/26/2024
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Last Update Date | 12/19/2025
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Provider Practice Location Address
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Address Line | 6070 S 2000 W
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City | REXBURG
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State | ID
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Zip | 83440-4441
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Country | US
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Telephone | 208-356-3340
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Fax | 833-520-1454
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Provider Business Mailing Address
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Address Line | 6070 S 2000 W
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City | REXBURG
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State | ID
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Zip | 83440-4441
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Country | US
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Telephone | 208-356-3340
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Fax | 833-520-1454
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | AMANDA LAGERSTROM
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Credential | MOTL/R
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Telephone | 208-356-3340
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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