Provider Demographics
NPI:1487664371
Name:SANDPOINT PHYSICAL THERAPY & AQUATIC CENTER
Entity Type:Organization
Organization Name:SANDPOINT PHYSICAL THERAPY & AQUATIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RUDOLF
Authorized Official - Middle Name:
Authorized Official - Last Name:KREPS
Authorized Official - Suffix:
Authorized Official - Credentials:LPT
Authorized Official - Phone:208-263-8866
Mailing Address - Street 1:1301 N DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-8268
Mailing Address - Country:US
Mailing Address - Phone:208-263-8866
Mailing Address - Fax:
Practice Address - Street 1:1301 N DIVISION AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-8268
Practice Address - Country:US
Practice Address - Phone:208-263-8866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT9818OtherBLUE CROSS GROUP PROVIDER
ID1654354Medicare ID - Type Unspecified