Provider Demographics
NPI:1023129251
Name:WALLENTINE, BRUCE J (MPT)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:J
Last Name:WALLENTINE
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 LANARK RD
Mailing Address - Street 2:
Mailing Address - City:OVID
Mailing Address - State:ID
Mailing Address - Zip Code:83254-4934
Mailing Address - Country:US
Mailing Address - Phone:208-945-2900
Mailing Address - Fax:208-945-2900
Practice Address - Street 1:900 LANARK RD
Practice Address - Street 2:
Practice Address - City:OVID
Practice Address - State:ID
Practice Address - Zip Code:83254-4934
Practice Address - Country:US
Practice Address - Phone:208-945-2900
Practice Address - Fax:208-945-2900
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-593225100000X
WYPT-389225100000X
UT362968-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist