Provider Demographics
NPI:1962035469
Name:RACINE, KEVIN DOUGLAS (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:RACINE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5915
Mailing Address - Country:US
Mailing Address - Phone:208-939-9594
Mailing Address - Fax:208-939-9828
Practice Address - Street 1:1618 S MILLENIUM WAY STE 210
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6457
Practice Address - Country:US
Practice Address - Phone:208-884-4647
Practice Address - Fax:208-884-8984
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist