Provider Demographics
NPI:1184612772
Name:HAILEY SPORT AND SPINE PHYSICAL THERAPY PA
Entity type:Organization
Organization Name:HAILEY SPORT AND SPINE PHYSICAL THERAPY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAZIK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-788-6312
Mailing Address - Street 1:PO BOX 1693
Mailing Address - Street 2:810 S MAIN ST STE 7A
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-1693
Mailing Address - Country:US
Mailing Address - Phone:208-788-6312
Mailing Address - Fax:208-578-1053
Practice Address - Street 1:810 S MAIN ST
Practice Address - Street 2:STE 7A
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8426
Practice Address - Country:US
Practice Address - Phone:208-788-6312
Practice Address - Fax:208-578-1053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1168225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1379208Medicare ID - Type UnspecifiedGROUP #