Provider Demographics
NPI:1255996468
Name:BROADHEAD, ELLIOT DUANE (DPT)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:DUANE
Last Name:BROADHEAD
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 W AIRBASE RD APT 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3344
Mailing Address - Country:US
Mailing Address - Phone:208-730-7467
Mailing Address - Fax:
Practice Address - Street 1:527 5TH AVE #500
Practice Address - Street 2:
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311
Practice Address - Country:US
Practice Address - Phone:208-828-4626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist