Provider Demographics
NPI:1831211093
Name:FOOTHILLS REHABILITATION & PERFORMANCE SERVICES
Entity type:Organization
Organization Name:FOOTHILLS REHABILITATION & PERFORMANCE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:SHELDON
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-529-3562
Mailing Address - Street 1:3814 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7591
Mailing Address - Country:US
Mailing Address - Phone:208-529-3562
Mailing Address - Fax:208-529-4064
Practice Address - Street 1:3814 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7591
Practice Address - Country:US
Practice Address - Phone:208-529-3562
Practice Address - Fax:208-529-4064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy