Provider Demographics
NPI:1477566941
Name:JOSHUA TREE PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:JOSHUA TREE PHYSICAL THERAPY PLLC
Other - Org Name:AFFORDABLE EXCELLENCE IN PHYSICAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER-OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SGROI
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-772-9774
Mailing Address - Street 1:8300 N WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-6027
Mailing Address - Country:US
Mailing Address - Phone:208-772-9774
Mailing Address - Fax:208-772-9564
Practice Address - Street 1:8300 N WAYNE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6027
Practice Address - Country:US
Practice Address - Phone:208-772-9774
Practice Address - Fax:208-772-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1457174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807014300Medicaid
ID=========Medicare UPIN
ID807014300Medicaid