Provider Demographics
NPI:1447383625
Name:PINNACLE PHYSICAL THERAPY AND SPORTS MEDICINE, INC
Entity Type:Organization
Organization Name:PINNACLE PHYSICAL THERAPY AND SPORTS MEDICINE, INC
Other - Org Name:SUMMIT REHABILITATION ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:BENGTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-777-4242
Mailing Address - Street 1:1590 E POLSTON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5218
Mailing Address - Country:US
Mailing Address - Phone:208-777-4242
Mailing Address - Fax:208-777-4020
Practice Address - Street 1:1590 E POLSTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5218
Practice Address - Country:US
Practice Address - Phone:208-777-4242
Practice Address - Fax:208-777-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2007-09-11
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
ID000010160541OtherREGENCE BLUESHIELD
IDT9333OtherBLUE CROSS
ID1366613Medicare PIN