Provider Demographics
NPI:1215381181
Name:SPECIALIZED PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:SPECIALIZED PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HIGBEE
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT
Authorized Official - Phone:208-242-8617
Mailing Address - Street 1:4141 POLELINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4904
Mailing Address - Country:US
Mailing Address - Phone:208-242-8617
Mailing Address - Fax:833-698-2470
Practice Address - Street 1:4141 POLELINE RD STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202
Practice Address - Country:US
Practice Address - Phone:208-242-8617
Practice Address - Fax:833-698-2470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-18
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3095261QP2000X
261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy