Provider Demographics
NPI:1689770711
Name:PRO MOTION PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PRO MOTION PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER / MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GAVIN
Authorized Official - Middle Name:MCEACHERN
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-336-1042
Mailing Address - Street 1:4725 SAMARA ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3642
Mailing Address - Country:US
Mailing Address - Phone:208-336-1042
Mailing Address - Fax:
Practice Address - Street 1:1101 N 28TH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-2208
Practice Address - Country:US
Practice Address - Phone:208-336-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-15162251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty