Provider Demographics
NPI:1477608834
Name:PROGRESSIVE THERAPY PC
Entity Type:Organization
Organization Name:PROGRESSIVE THERAPY PC
Other - Org Name:IDAHO PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-454-0505
Mailing Address - Street 1:206 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4815
Mailing Address - Country:US
Mailing Address - Phone:208-454-0505
Mailing Address - Fax:208-454-0559
Practice Address - Street 1:206 E ELM ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4815
Practice Address - Country:US
Practice Address - Phone:208-454-0505
Practice Address - Fax:208-454-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1374139Medicare ID - Type Unspecified