MEDICARE: PICK PT PHYSICAL THERAPY LLC

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1477183168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PICK PT PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	2277 E LINCOLN RD
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2202
Country	:	US
Telephone Number	:	208-881-3616
Fax Number	:	208-534-7002

Provider Business Practice Location Address
First Line	:	2277 E LINCOLN RD
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2202
Country	:	US
Telephone Number	:	208-534-7001
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICAL THERAPIST
Name	:	CORDELL PICKERING
Credential	:
Telephone Number	:	208-701-1800

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/31/2022

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