MEDICARE: RESTORE PHYSICAL THERAPY PC

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	PT-1804	ID

General Provider Information

NPI Number	:	1790236511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORE PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	5418 N EAGLE RD
Second Line	:	SUITE 170
City	:	BOISE
State	:	ID
Zip	:	83713-0998
Country	:	US
Telephone Number	:	208-939-3332
Fax Number	:	208-939-3338

Provider Business Practice Location Address
First Line	:	5418 N EAGLE RD
Second Line	:	SUITE 170
City	:	BOISE
State	:	ID
Zip	:	83713-0998
Country	:	US
Telephone Number	:	208-501-8264
Fax Number	:	208-514-1558

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. SARAH GRAHAM
Credential	:	P.T.
Telephone Number	:	208-501-8264

Provider Enumeration Date	:	10/17/2016
Last Update Date	:	01/10/2024

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