Provider Demographics
NPI:1487630240
Name:THERAPEUTIC ASSOCIATES INC
Entity Type:Organization
Organization Name:THERAPEUTIC ASSOCIATES INC
Other - Org Name:TAI SE BOISE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INFORMATION SYSTEMS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:503-443-6156
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:960 S BROADWAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3600
Practice Address - Country:US
Practice Address - Phone:208-433-9211
Practice Address - Fax:208-433-9241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1487630240-000Medicaid
ID197670349Medicaid
ID1487630240Medicaid
ID197670349OtherOWCP
ID1487630240Medicaid