Provider Demographics
NPI:1215011754
Name:S.P.O.R.T. PHYSICAL THERAPY CLINIC
Entity Type:Organization
Organization Name:S.P.O.R.T. PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEIGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-746-7573
Mailing Address - Street 1:328 WARNER DR
Mailing Address - Street 2:STE 8
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4441
Mailing Address - Country:US
Mailing Address - Phone:208-746-7573
Mailing Address - Fax:208-746-4519
Practice Address - Street 1:328 WARNER DR
Practice Address - Street 2:STE 8
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4441
Practice Address - Country:US
Practice Address - Phone:208-746-7573
Practice Address - Fax:208-746-4519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID04-152355261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806463300Medicaid
ID806463300Medicaid
ID0779370001Medicare NSC