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General NPI Number Information
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NPI Number | 1962424952
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Entity Type | Organization
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Legal Business Name | CLIFFORD L KIRACOFE PT PA
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 06/12/2008
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Provider Practice Location Address
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Address Line | 8836 N HESS ST STE C
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City | HAYDEN
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State | ID
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Zip | 83835-8718
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Country | US
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Telephone | 208-772-6991
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Fax | 208-772-6674
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Provider Business Mailing Address
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Address Line | PO BOX 293
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City | HAYDEN
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State | ID
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Zip | 83835-0293
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Country | US
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Telephone | 208-772-6991
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Fax | 208-772-6674
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Authorized Official
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Title or Position | OWNER
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Name | CLIFFORD KIRACOFE
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Credential |
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Telephone | 208-772-6991
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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 | 1620
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License Number State | MT
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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 | PT1579
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License Number State | ID
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