Provider Demographics
NPI:1184972184
Name:PERIWINKLE CHILDREN'S THERAPY
Entity type:Organization
Organization Name:PERIWINKLE CHILDREN'S THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-762-3502
Mailing Address - Street 1:1401 W BIZZTOWN LOOP
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5113
Mailing Address - Country:US
Mailing Address - Phone:208-762-3502
Mailing Address - Fax:888-310-4824
Practice Address - Street 1:1401 W BIZZTOWN LOOP
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-5113
Practice Address - Country:US
Practice Address - Phone:208-762-3502
Practice Address - Fax:888-310-4824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-22
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty