Provider Demographics
NPI:1821101064
Name:SEAGRAVE, CHRISTOPHER J (PT, SCS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:SEAGRAVE
Suffix:
Gender:M
Credentials:PT, SCS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7979 W RIFLEMAN ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9066
Mailing Address - Country:US
Mailing Address - Phone:208-938-8020
Mailing Address - Fax:208-938-8016
Practice Address - Street 1:533 S RIVERSHORE LN
Practice Address - Street 2:STE 120
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4979
Practice Address - Country:US
Practice Address - Phone:208-938-8020
Practice Address - Fax:208-938-8016
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT2566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WASE5492OtherREGENCE BLUE SHIELD
WA60017398OtherRAILROAD MEDICARE
WA118290OtherDEPT OF LABOR & INDUSTRIE
WA8334195Medicaid
WAA005OtherTRICARE
ID1821101064Medicaid
WA8923419OtherCRIME VICTIMS
WA60017398OtherRAILROAD MEDICARE