Provider Demographics
NPI:1770678484
Name:SGROI, KEVIN JOHN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:SGROI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 N WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-6027
Mailing Address - Country:US
Mailing Address - Phone:208-772-9774
Mailing Address - Fax:208-772-9564
Practice Address - Street 1:8300 N WAYNE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-6027
Practice Address - Country:US
Practice Address - Phone:208-772-9774
Practice Address - Fax:208-772-9564
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807014300Medicaid
ID807014300Medicaid
ID141892738Medicare UPIN