Provider Demographics
NPI:1477093334
Name:FULL POTENTIAL PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:FULL POTENTIAL PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SAKER
Authorized Official - Middle Name:RAVEE
Authorized Official - Last Name:MEDAVARAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-816-8836
Mailing Address - Street 1:450 THAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5300
Mailing Address - Country:US
Mailing Address - Phone:208-816-8836
Mailing Address - Fax:208-746-0873
Practice Address - Street 1:450 THAIN RD STE A
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5300
Practice Address - Country:US
Practice Address - Phone:208-816-8836
Practice Address - Fax:208-621-2995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-26
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1243261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy