Provider Demographics
NPI:1477573087
Name:TREASURE VALLEY PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:TREASURE VALLEY PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUDLEIGH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:541-889-2221
Mailing Address - Street 1:PO BOX 1336
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-1054
Mailing Address - Country:US
Mailing Address - Phone:541-889-2221
Mailing Address - Fax:541-889-3437
Practice Address - Street 1:2671 SW 4TH AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-1833
Practice Address - Country:US
Practice Address - Phone:541-889-2221
Practice Address - Fax:541-889-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR132075Medicare PIN