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General NPI Number Information
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NPI Number | 1861173247
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Entity Type | Individual
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Provider Name | RILEY D WALDECK DPT
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Gender | Male
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Dates
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Enumeration Date | 07/27/2023
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Last Update Date | 07/27/2023
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Provider Practice Location Address
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Address Line | 3157 E BARBER VALLEY DR STE 120
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City | BOISE
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State | ID
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Zip | 83716-4770
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Country | US
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Telephone | 208-901-8477
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Fax | 208-629-7529
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Provider Business Mailing Address
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Address Line | 1411 FALLS AVE E STE 401
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City | TWIN FALLS
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State | ID
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Zip | 83301-3455
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Country | US
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Telephone | 208-901-8477
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Fax | 208-629-7529
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | PT8820
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License Number State | ID
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