Provider Demographics
NPI:1093031957
Name:PACE, LADEAN I (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LADEAN
Middle Name:I
Last Name:PACE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 E 1557 S
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:ID
Mailing Address - Zip Code:83342-7700
Mailing Address - Country:US
Mailing Address - Phone:208-645-2622
Mailing Address - Fax:
Practice Address - Street 1:1501 HILAND AVE
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2682
Practice Address - Country:US
Practice Address - Phone:208-678-4444
Practice Address - Fax:208-677-6306
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-160225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant