Provider Demographics
NPI:1902182298
Name:FUNCTIONAL PHYSICAL THERAPY CENTER
Entity Type:Organization
Organization Name:FUNCTIONAL PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAJCOOMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ISSUREE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-376-7313
Mailing Address - Street 1:8950 W EMERALD ST
Mailing Address - Street 2:SUITE 195
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4854
Mailing Address - Country:US
Mailing Address - Phone:208-376-7313
Mailing Address - Fax:208-376-7487
Practice Address - Street 1:8950 W EMERALD ST
Practice Address - Street 2:SUITE 195
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4854
Practice Address - Country:US
Practice Address - Phone:208-376-7313
Practice Address - Fax:208-376-7487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT670261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy