Provider Demographics
NPI:1427029610
Name:CENTER FOR PHYSICAL REHABILITATION, LLC
Entity Type:Organization
Organization Name:CENTER FOR PHYSICAL REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-734-5313
Mailing Address - Street 1:754 N COLLEGE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5822
Mailing Address - Country:US
Mailing Address - Phone:208-734-5313
Mailing Address - Fax:208-736-1582
Practice Address - Street 1:754 N COLLEGE RD
Practice Address - Street 2:SUITE D
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5822
Practice Address - Country:US
Practice Address - Phone:208-734-5313
Practice Address - Fax:208-736-1582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT-267225100000X
IDRPT-208225100000X
IDRPT-432225100000X
IDRPT-1549225100000X
IDRPT-1620225100000X
IDPT-2561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002620200Medicaid
ID002620200Medicaid