Provider Demographics
NPI:1285014779
Name:BOISE RIVER PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BOISE RIVER PHYSICAL THERAPY
Other - Org Name:BOISE RIVER PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:LINK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT, OCS, CSCS
Authorized Official - Phone:815-540-6065
Mailing Address - Street 1:64 S STAR ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669
Mailing Address - Country:US
Mailing Address - Phone:815-540-6065
Mailing Address - Fax:815-380-6355
Practice Address - Street 1:64 S STAR ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669
Practice Address - Country:US
Practice Address - Phone:815-540-6065
Practice Address - Fax:815-380-6355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-01
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070011785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty