Provider Demographics
NPI:1073956306
Name:PT MEDICAL LLC
Entity Type:Organization
Organization Name:PT MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-364-8144
Mailing Address - Street 1:PO BOX 51630
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405-1630
Mailing Address - Country:US
Mailing Address - Phone:630-364-8144
Mailing Address - Fax:866-661-4322
Practice Address - Street 1:490 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3656
Practice Address - Country:US
Practice Address - Phone:630-364-8144
Practice Address - Fax:866-661-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies