Provider Demographics
NPI:1265524045
Name:KOTH SPORTS PHYSICAL THERAPY, PA
Entity type:Organization
Organization Name:KOTH SPORTS PHYSICAL THERAPY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ITS SECRETARY/TREASURER, ITS BUS MG
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-788-3997
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-1510
Mailing Address - Country:US
Mailing Address - Phone:208-788-3997
Mailing Address - Fax:208-726-1607
Practice Address - Street 1:101 SADDLE ROAD
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-1510
Practice Address - Country:US
Practice Address - Phone:208-726-9222
Practice Address - Fax:208-726-1607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDDC6231OtherRAILROAD MEDICARE GROUP
ID1376033Medicare ID - Type UnspecifiedMEDICARE GROUP