Provider Demographics
NPI:1891882486
Name:REBOUND PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:REBOUND PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:LANGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPT, OCS
Authorized Official - Phone:208-939-3332
Mailing Address - Street 1:1175 E PARKCENTER BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6751
Mailing Address - Country:US
Mailing Address - Phone:208-344-2525
Mailing Address - Fax:208-344-3056
Practice Address - Street 1:1175 E PARKCENTER BLVD
Practice Address - Street 2:STE 104
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6751
Practice Address - Country:US
Practice Address - Phone:208-344-2525
Practice Address - Fax:208-344-3056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT9401OtherBLUE CROSS
ID807277100Medicaid
000010151218OtherBLUE SHIELD
000010151218OtherBLUE SHIELD