Provider Demographics
NPI:1073038378
Name:STREAMLINE SPORTS PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:STREAMLINE SPORTS PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:
Authorized Official - First Name:BLAIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZIKRATCH-CLAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-269-2360
Mailing Address - Street 1:335 E LEWIS ST STE 10
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6408
Mailing Address - Country:US
Mailing Address - Phone:208-269-2360
Mailing Address - Fax:208-550-3256
Practice Address - Street 1:335 E LEWIS ST STE 10
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6408
Practice Address - Country:US
Practice Address - Phone:208-269-2360
Practice Address - Fax:208-550-3256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-08
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2831225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty