Provider Demographics
NPI:1306852850
Name:PHYSIOTHERAPY P.A.
Entity Type:Organization
Organization Name:PHYSIOTHERAPY P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FLECKENSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-938-8020
Mailing Address - Street 1:661 S RIVERSHORE LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5396
Mailing Address - Country:US
Mailing Address - Phone:208-938-8020
Mailing Address - Fax:208-938-8016
Practice Address - Street 1:661 S RIVERSHORE LN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5396
Practice Address - Country:US
Practice Address - Phone:208-938-8020
Practice Address - Fax:208-938-8016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378171Medicare ID - Type UnspecifiedMEDICARE GROUP #