Provider Demographics
NPI:1750478327
Name:EAGLE PHYSICAL THERAPY PA
Entity type:Organization
Organization Name:EAGLE PHYSICAL THERAPY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:K
Authorized Official - Last Name:LANGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, OCS
Authorized Official - Phone:208-939-3332
Mailing Address - Street 1:457 S FITNESS PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6568
Mailing Address - Country:US
Mailing Address - Phone:208-939-3332
Mailing Address - Fax:208-939-3338
Practice Address - Street 1:457 S FITNESS PL
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6568
Practice Address - Country:US
Practice Address - Phone:208-939-3332
Practice Address - Fax:208-939-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806054600Medicaid
T9420OtherBLUE CROSS
DB2265OtherRAILROAD MEDICARE
000010026792OtherBLUE SHIELD
332828OtherPRIVATE HEALTHCARE SYSTEM
ID806054600Medicaid