Provider Demographics
NPI:1184097271
Name:RUTTEN, RONALD
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:RUTTEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1872 N HONEYSUCKLE LN
Mailing Address - Street 2:
Mailing Address - City:INKOM
Mailing Address - State:ID
Mailing Address - Zip Code:83245-1612
Mailing Address - Country:US
Mailing Address - Phone:208-775-3531
Mailing Address - Fax:
Practice Address - Street 1:300 S 3RD W
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276-1559
Practice Address - Country:US
Practice Address - Phone:208-547-3341
Practice Address - Fax:208-547-2790
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-433225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-433OtherBUREAU OF OCCUPATIONAL LICENSES