Provider Demographics
NPI:1164654398
Name:HAND AND UPPER EXTREMITY CENTER, INC
Entity Type:Organization
Organization Name:HAND AND UPPER EXTREMITY CENTER, INC
Other - Org Name:HANDX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:JEAN
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L, CHT
Authorized Official - Phone:208-478-0258
Mailing Address - Street 1:560 MEMORIAL DR STE B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4073
Mailing Address - Country:US
Mailing Address - Phone:208-478-0258
Mailing Address - Fax:208-269-7336
Practice Address - Street 1:560 MEMORIAL DR STE B
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4073
Practice Address - Country:US
Practice Address - Phone:208-478-0258
Practice Address - Fax:208-269-7336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-612225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6351800001Medicare NSC