Provider Demographics
NPI:1043716285
Name:ANDERSON, BRICE (MSAT, LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:BRICE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:MSAT, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 SARATOGA ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2253
Mailing Address - Country:US
Mailing Address - Phone:208-242-8650
Mailing Address - Fax:
Practice Address - Street 1:777 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5175
Practice Address - Country:US
Practice Address - Phone:208-242-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer