Provider Demographics
NPI:1881816304
Name:HARDCASTLE, IVAN M (MOT)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:M
Last Name:HARDCASTLE
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 EASTLAND DR N STE A
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4458
Mailing Address - Country:US
Mailing Address - Phone:208-308-4661
Mailing Address - Fax:208-736-0890
Practice Address - Street 1:276 EASTLAND DR N STE A
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4458
Practice Address - Country:US
Practice Address - Phone:208-308-4661
Practice Address - Fax:208-736-0890
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTLP240225X00000X
IDOT-831225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist