Provider Demographics
NPI:1710163951
Name:MOBLEY PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:MOBLEY PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:ERROL
Authorized Official - Last Name:MOBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:208-745-8332
Mailing Address - Street 1:151 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1417
Mailing Address - Country:US
Mailing Address - Phone:208-745-8332
Mailing Address - Fax:208-745-8272
Practice Address - Street 1:151 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1417
Practice Address - Country:US
Practice Address - Phone:208-745-8332
Practice Address - Fax:208-745-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRPT895261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID136534OtherMEDICARE PART A
ID805445700Medicaid
ID136534Medicare Oscar/Certification