MEDICARE: MR. GALEN EUGENE DANIELSON DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PT-1534	ID
2	225100000X	Physical Therapist	PT-1534	ID

General Provider Information

NPI Number	:	1225123599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GALEN EUGENE DANIELSON DPT

Provider Business Mailing Address
First Line	:	1560 S CAROL ST
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-1839
Country	:	US
Telephone Number	:	208-288-1155
Fax Number	:	208-288-0424

Provider Business Practice Location Address
First Line	:	5520 N. EAGLE ROAD
Second Line	:	SUITE 102
City	:	BOISE
State	:	ID
Zip	:	83713-0998
Country	:	US
Telephone Number	:	208-938-5255
Fax Number	:	208-938-5545

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	03/12/2013

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