Provider Demographics
NPI:1700433919
Name:BATES, MATTHEW LARSON (DPT,PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LARSON
Last Name:BATES
Suffix:
Gender:M
Credentials:DPT,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-736-2574
Mailing Address - Fax:208-736-2594
Practice Address - Street 1:243 CHENEY DR W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4277
Practice Address - Country:US
Practice Address - Phone:087-362-5742
Practice Address - Fax:208-736-2594
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6494225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist