Provider Demographics
NPI:1245766518
Name:IDAHO SPINE AND SPORTS PHYSICAL THERAPY - SILVERSTONE
Entity Type:Organization
Organization Name:IDAHO SPINE AND SPORTS PHYSICAL THERAPY - SILVERSTONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRET
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-939-0533
Mailing Address - Street 1:2316 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2665
Mailing Address - Country:US
Mailing Address - Phone:208-286-2707
Mailing Address - Fax:208-286-2743
Practice Address - Street 1:2316 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2665
Practice Address - Country:US
Practice Address - Phone:208-286-2707
Practice Address - Fax:208-286-2743
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO SPINE & SPORTS PHYSICAL THERAPY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2983225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty