Provider Demographics
NPI:1558828020
Name:SANDPOINT PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:SANDPOINT PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:THOME
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:210-393-8090
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:208-265-0610
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:208-265-0610
Practice Address - Fax:208-265-9192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1215237201Medicaid