Provider Demographics
NPI:1053633313
Name:TETON PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:TETON PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:GRIFFETH
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-529-3355
Mailing Address - Street 1:2037 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6430
Mailing Address - Country:US
Mailing Address - Phone:208-529-3355
Mailing Address - Fax:208-529-9581
Practice Address - Street 1:2037 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6430
Practice Address - Country:US
Practice Address - Phone:208-529-3355
Practice Address - Fax:208-529-9581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT6232251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002714400Medicaid