Provider Demographics
NPI:1467749788
Name:ALLRED, KEVIN LAWRENCE (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LAWRENCE
Last Name:ALLRED
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-1185
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:1435 S MAPLE GROVE RD
Practice Address - Street 2:STE 201
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1611
Practice Address - Country:US
Practice Address - Phone:208-322-6200
Practice Address - Fax:208-322-6233
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID136523Medicare Oscar/Certification