Provider Demographics
NPI:1891000386
Name:KING PHYSICAL THERAPY P.C.
Entity Type:Organization
Organization Name:KING PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-477-8028
Mailing Address - Street 1:PO BOX 1056
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-1056
Mailing Address - Country:US
Mailing Address - Phone:208-477-8028
Mailing Address - Fax:208-287-9426
Practice Address - Street 1:103 S COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2921
Practice Address - Country:US
Practice Address - Phone:208-477-8028
Practice Address - Fax:208-287-9426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-09
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1924225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID16528661Medicare PIN