Provider Demographics
NPI:1073718391
Name:VALLEY VISTA THERAPY SERVICES
Entity Type:Organization
Organization Name:VALLEY VISTA THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-245-4576
Mailing Address - Street 1:820 ELM ST
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-2119
Mailing Address - Country:US
Mailing Address - Phone:208-245-4576
Mailing Address - Fax:208-245-5909
Practice Address - Street 1:820 ELM ST
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2119
Practice Address - Country:US
Practice Address - Phone:208-245-4576
Practice Address - Fax:208-245-5909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-5102083X0100X
IDOT-0612083X0100X
IDSLP-1123235Z00000X
IDPT-160261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Not Answered261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy