Provider Demographics
NPI:1700128337
Name:HYDE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:HYDE PHYSICAL THERAPY
Other - Org Name:HYDE ELLIS PHYSICAL THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICALS THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:R
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-227-6255
Mailing Address - Street 1:725 JENSEN GROVE DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1636
Mailing Address - Country:US
Mailing Address - Phone:208-785-3462
Mailing Address - Fax:208-785-3453
Practice Address - Street 1:725 JENSEN GROVE DR
Practice Address - Street 2:SUITE 4
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1636
Practice Address - Country:US
Practice Address - Phone:208-785-3462
Practice Address - Fax:208-785-3453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-21
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1987261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy