Provider Demographics
NPI:1295597763
Name:MOUNTAIN WEST SPORT AND SPINE PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:MOUNTAIN WEST SPORT AND SPINE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPPETTO
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:253-334-0178
Mailing Address - Street 1:1826 N HENDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-6466
Mailing Address - Country:US
Mailing Address - Phone:253-334-0178
Mailing Address - Fax:
Practice Address - Street 1:649 N CLIFF CREEK LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1071
Practice Address - Country:US
Practice Address - Phone:253-334-0178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service