Provider Demographics
NPI:1568645554
Name:PHYSICAL THERAPY AND SPORTS MEDICINE CLINIC INC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AND SPORTS MEDICINE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:B
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-745-8580
Mailing Address - Street 1:4102 E 82 N
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-5894
Mailing Address - Country:US
Mailing Address - Phone:208-745-8580
Mailing Address - Fax:208-745-8580
Practice Address - Street 1:4102 E 82 N
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-5894
Practice Address - Country:US
Practice Address - Phone:208-745-8580
Practice Address - Fax:208-745-8580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDT 236225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002591700Medicaid
ID806469200Medicaid
ID1654675Medicare PIN
ID1650444Medicare PIN