Provider Demographics
NPI:1831424878
Name:PRESTON PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PRESTON PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-852-1143
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:UT
Mailing Address - Zip Code:84320-0014
Mailing Address - Country:US
Mailing Address - Phone:435-770-5199
Mailing Address - Fax:208-852-3951
Practice Address - Street 1:10 S 100 W STE A
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1244
Practice Address - Country:US
Practice Address - Phone:208-852-1143
Practice Address - Fax:208-852-3951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty