Provider Demographics
NPI:1619045309
Name:ALTITUDE PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:ALTITUDE PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEATHERSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-454-9839
Mailing Address - Street 1:1906 FAIRVIEW AVE STE 410
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5424
Mailing Address - Country:US
Mailing Address - Phone:208-454-9839
Mailing Address - Fax:208-454-0727
Practice Address - Street 1:1906 FAIRVIEW AVE STE 410
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5424
Practice Address - Country:US
Practice Address - Phone:208-454-9839
Practice Address - Fax:208-454-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807229400Medicaid