Provider Demographics
NPI:1225162597
Name:THERAPY FOR LIFE
Entity Type:Organization
Organization Name:THERAPY FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHIBALD
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:208-351-0651
Mailing Address - Street 1:P.O. BOX 354
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427
Mailing Address - Country:US
Mailing Address - Phone:208-351-0651
Mailing Address - Fax:208-528-0989
Practice Address - Street 1:4893 CAMAS CREEK CIRCLE
Practice Address - Street 2:
Practice Address - City:IONA
Practice Address - State:ID
Practice Address - Zip Code:83427
Practice Address - Country:US
Practice Address - Phone:208-351-0651
Practice Address - Fax:208-528-0989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1655702Medicare ID - Type UnspecifiedPROVIDER NUMBER
ID1377723Medicare ID - Type UnspecifiedGROUP PRICING NUMBER