Provider Demographics
NPI:1295129476
Name:LORAINE, ALICE (DPT, OMS)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:LORAINE
Suffix:
Gender:F
Credentials:DPT, OMS
Other - Prefix:
Other - First Name:ALI
Other - Middle Name:
Other - Last Name:LORAINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT, OMS
Mailing Address - Street 1:210 TRIANGLE DR STE E
Mailing Address - Street 2:
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-9791
Mailing Address - Country:US
Mailing Address - Phone:208-946-5364
Mailing Address - Fax:208-946-5364
Practice Address - Street 1:210 TRIANGLE DR STE E
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9791
Practice Address - Country:US
Practice Address - Phone:208-946-5364
Practice Address - Fax:208-946-5364
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-25
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3693225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist