Provider Demographics
NPI:1144504812
Name:FLICKER PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FLICKER PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FLICKER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-406-2057
Mailing Address - Street 1:2839 MARGO LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-1961
Mailing Address - Country:US
Mailing Address - Phone:208-406-2057
Mailing Address - Fax:
Practice Address - Street 1:4922 YELLOWSTONE AVE STE J
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2360
Practice Address - Country:US
Practice Address - Phone:208-237-1882
Practice Address - Fax:208-904-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty