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General NPI Number Information
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NPI Number | 1902182298
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Entity Type | Organization
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Legal Business Name | FUNCTIONAL PHYSICAL THERAPY CENTER
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Dates
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Enumeration Date | 10/31/2011
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Last Update Date | 04/16/2012
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Provider Practice Location Address
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Address Line | 8950 W EMERALD ST SUITE 195
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City | BOISE
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State | ID
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Zip | 83704-4854
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Country | US
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Telephone | 208-376-7313
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Fax | 208-376-7487
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Provider Business Mailing Address
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Address Line | 8950 W EMERALD ST SUITE 195
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City | BOISE
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State | ID
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Zip | 83704-4854
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Country | US
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Telephone | 208-376-7313
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Fax | 208-376-7487
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Authorized Official
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Title or Position | PHYSICAL THERAPIST/DIRECTOR
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Name | RAJCOOMAR ISSUREE
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Credential | P.T.
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Telephone | 208-376-7313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | PT670
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License Number State | ID
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