Provider Demographics
NPI:1356754147
Name:ADVANCED PHYSICAL THERAPY & WOUND CENTER, PLLC
Entity type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY & WOUND CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF THERAPY
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-359-2500
Mailing Address - Street 1:PO BOX 322
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0322
Mailing Address - Country:US
Mailing Address - Phone:208-359-2500
Mailing Address - Fax:208-359-2502
Practice Address - Street 1:1 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2024
Practice Address - Country:US
Practice Address - Phone:208-359-2500
Practice Address - Fax:208-359-2502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty