Provider Demographics
NPI:1336315175
Name:PROACTIVE PHYSICAL THERAPY OF MCCALL, PA
Entity Type:Organization
Organization Name:PROACTIVE PHYSICAL THERAPY OF MCCALL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MOIRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:STOTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-634-8517
Mailing Address - Street 1:PO BOX 2041
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-2041
Mailing Address - Country:US
Mailing Address - Phone:208-634-8517
Mailing Address - Fax:
Practice Address - Street 1:101 N COUNCIL AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:COUNCIL
Practice Address - State:ID
Practice Address - Zip Code:83612-0000
Practice Address - Country:US
Practice Address - Phone:208-253-6893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROACTIVE PHYSICAL THERAPY OF MCCALL, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1650928Medicare PIN