Provider Demographics
NPI:1821034513
Name:SANDS, CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SANDS
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 1:7550 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9015
Mailing Address - Country:US
Mailing Address - Phone:208-375-0666
Mailing Address - Fax:208-375-2996
Practice Address - Street 1:7550 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9015
Practice Address - Country:US
Practice Address - Phone:208-375-0666
Practice Address - Fax:208-375-2996
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010006921OtherBLUE SHIELD OF IDAHO
IDT8067OtherBLUE CROSS OF IDAHO
ID000010006921OtherBLUE SHIELD OF IDAHO