Provider Demographics
NPI:1669530051
Name:BURLEY PHYSICAL THERAPY AND REHABILITATION
Entity type:Organization
Organization Name:BURLEY PHYSICAL THERAPY AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-678-1191
Mailing Address - Street 1:1263 BENNETT AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-4906
Mailing Address - Country:US
Mailing Address - Phone:208-678-1191
Mailing Address - Fax:208-678-1214
Practice Address - Street 1:1263 BENNETT AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-4906
Practice Address - Country:US
Practice Address - Phone:208-678-1191
Practice Address - Fax:208-678-1214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QH0700X, 261QX0100X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010026864OtherBLUE SHIELD
IDT8604OtherBLUE CROSS
ID=========OtherTAX ID NUMBER