Provider Demographics
NPI:1568756716
Name:RANDKLEV, SCOTT (DPT)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:RANDKLEV
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6045
Mailing Address - Country:US
Mailing Address - Phone:208-777-7800
Mailing Address - Fax:208-777-9209
Practice Address - Street 1:1132 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6045
Practice Address - Country:US
Practice Address - Phone:208-777-7800
Practice Address - Fax:208-777-9209
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2816225100000X, 225100000X
MA19489225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1134149941Medicaid
ID1134149941Medicaid