Provider Demographics
NPI:1497061782
Name:MAIERS, BRET (PT)
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:
Last Name:MAIERS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 FLANDRO DR 190
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1975
Mailing Address - Country:US
Mailing Address - Phone:208-233-2248
Mailing Address - Fax:208-233-0219
Practice Address - Street 1:220 MILLPOND
Practice Address - Street 2:SUITE 109
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9745
Practice Address - Country:US
Practice Address - Phone:435-882-4144
Practice Address - Fax:435-882-4151
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60168625225100000X
UT8715597-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1497061782Medicaid
UT1497061782Medicaid
ORP00877701OtherRR MEDICARE
WAG8894867Medicare PIN