Provider Demographics
NPI:1518203249
Name:ELLIS PHYSICAL THERAPY P A
Entity Type:Organization
Organization Name:ELLIS PHYSICAL THERAPY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-523-8879
Mailing Address - Street 1:PO BOX 1463
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1463
Mailing Address - Country:US
Mailing Address - Phone:208-523-8879
Mailing Address - Fax:208-523-0436
Practice Address - Street 1:3100 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8310
Practice Address - Country:US
Practice Address - Phone:208-523-8879
Practice Address - Fax:208-523-0436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-28
Last Update Date:2018-04-20
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
ID804274500Medicaid