Provider Demographics
NPI:1659642775
Name:PHYSIOONE
Entity Type:Organization
Organization Name:PHYSIOONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACKWELDER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-758-0484
Mailing Address - Street 1:PO BOX 2834
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-2834
Mailing Address - Country:US
Mailing Address - Phone:208-818-9263
Mailing Address - Fax:208-485-4781
Practice Address - Street 1:8827 N GOVERNMENT WAY UNIT 106
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8231
Practice Address - Country:US
Practice Address - Phone:208-758-0484
Practice Address - Fax:208-485-4781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID008105Medicaid