Provider Demographics
NPI:1225235039
Name:MAYES PHYSICAL THERAPY, INC
Entity Type:Organization
Organization Name:MAYES PHYSICAL THERAPY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MHS
Authorized Official - Phone:208-644-1433
Mailing Address - Street 1:1976 S LINCOLN AVE
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-6150
Mailing Address - Country:US
Mailing Address - Phone:208-644-1433
Mailing Address - Fax:208-644-1434
Practice Address - Street 1:1976 S LINCOLN AVE
Practice Address - Street 2:SUITE 6A
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-6150
Practice Address - Country:US
Practice Address - Phone:208-644-1433
Practice Address - Fax:208-644-1434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID125261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1033262183OtherINDIVIDUAL NPI
ID000010023964OtherREGENCE BLUE SHIELD PIN
ID1002857OtherSTATE INSURANCE ID
ID125OtherSTATE ID LICENSE
ID0044033Medicaid
ID390146OtherREGENCE BLUE SHIELD ID
IDT2797OtherBLUE CROSS ID
ID1379198Medicare ID - Type UnspecifiedGROUP MEDICARE ID
ID390146OtherREGENCE BLUE SHIELD ID
ID125OtherSTATE ID LICENSE
ID0044033Medicaid