Provider Demographics
NPI:1801944400
Name:CENTER FOR ORTHOPEDIC REHABILITATION
Entity type:Organization
Organization Name:CENTER FOR ORTHOPEDIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:208-232-4267
Mailing Address - Street 1:275 S 5TH AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6410
Mailing Address - Country:US
Mailing Address - Phone:208-232-4267
Mailing Address - Fax:208-232-4268
Practice Address - Street 1:275 S 5TH AVE STE 140
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6410
Practice Address - Country:US
Practice Address - Phone:208-232-4267
Practice Address - Fax:208-232-4268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2487225100000X
IDPT-1730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806506300Medicaid
ID1654575Medicare ID - Type UnspecifiedJOHN T BATES MEDICARE
ID6032670001Medicare NSC