Provider Demographics
NPI:1740483411
Name:ADVANCE PHYSICAL THERAPY FOR ORTHOPAEDIC AND SPORTS INJURIES, LLC
Entity type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY FOR ORTHOPAEDIC AND SPORTS INJURIES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-672-8144
Mailing Address - Street 1:9362 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2505
Mailing Address - Country:US
Mailing Address - Phone:208-672-8144
Mailing Address - Fax:208-672-8145
Practice Address - Street 1:9362 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2505
Practice Address - Country:US
Practice Address - Phone:208-672-8144
Practice Address - Fax:208-672-8145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT1431225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376500124OtherNPI
1437187663OtherNPI
ID1093929812OtherNPI
ID805751600Medicaid
ID805753950Medicaid
1376500124OtherNPI
ID805751600Medicaid