Provider Demographics
NPI:1851509327
Name:LEPAK, CHAD IVES (PT)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:IVES
Last Name:LEPAK
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 1:3812 LA MESITA WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-1537
Mailing Address - Country:US
Mailing Address - Phone:208-385-0350
Mailing Address - Fax:
Practice Address - Street 1:3812 LA MESITA WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-1537
Practice Address - Country:US
Practice Address - Phone:208-385-0350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist