Provider Demographics
NPI:1780163303
Name:SIMMONS, CHAD R (DPT)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:R
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:RIRIE
Mailing Address - State:ID
Mailing Address - Zip Code:83443-0273
Mailing Address - Country:US
Mailing Address - Phone:208-900-6336
Mailing Address - Fax:208-900-4408
Practice Address - Street 1:245 MAIN ST
Practice Address - Street 2:
Practice Address - City:RIRIE
Practice Address - State:ID
Practice Address - Zip Code:83443
Practice Address - Country:US
Practice Address - Phone:208-900-6336
Practice Address - Fax:208-900-4408
Is Sole Proprietor?:No
Enumeration Date:2018-08-14
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-5816225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist