MEDICARE: KINTSUGI PHYSICAL THERAPY

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	:	1598300824
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KINTSUGI PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	1940 S BONITO WAY STE 190
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-5618
Country	:	US
Telephone Number	:	208-287-9420
Fax Number	:	208-287-9426

Provider Business Practice Location Address
First Line	:	17833 1ST AVE S STE A
Second Line	:
City	:	NORMANDY PARK
State	:	WA
Zip	:	98148-1713
Country	:	US
Telephone Number	:	253-330-8518
Fax Number	:	253-330-8519

Authorized Official
Title or Position	:	OWNER/PT
Name	:	CHRISTY RILEY
Credential	:	DPT
Telephone Number	:	253-330-8518

Provider Enumeration Date	:	11/11/2019
Last Update Date	:	03/13/2023

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