Provider Demographics
NPI:1578076519
Name:PIERCE PHYSICAL THERAPY AND SPORTS REHAB LLC
Entity Type:Organization
Organization Name:PIERCE PHYSICAL THERAPY AND SPORTS REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-371-2610
Mailing Address - Street 1:1532 W CAYUSE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4795
Mailing Address - Country:US
Mailing Address - Phone:208-996-6612
Mailing Address - Fax:
Practice Address - Street 1:1532 W CAYUSE CREEK DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4795
Practice Address - Country:US
Practice Address - Phone:208-996-6612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3309225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty