MEDICARE: MRS. TWILA ROSE DOVER P.T.

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	1679	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	T6160	OTHER	ID	BLUE CROSS
2	000010137787	OTHER	ID	BLUE SHIELD

General Provider Information

NPI Number	:	1538165170
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TWILA ROSE DOVER P.T.

Provider Business Mailing Address
First Line	:	5255 OVERLAND RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83705-2637
Country	:	US
Telephone Number	:	208-338-9486
Fax Number	:	208-338-9586

Provider Business Practice Location Address
First Line	:	5255 OVERLAND RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83705-2637
Country	:	US
Telephone Number	:	208-338-9486
Fax Number	:	208-338-9586

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/08/2007

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