Provider Demographics
NPI:1023675287
Name:RICCI, MATTHEW JOHN (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:RICCI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-969-9945
Mailing Address - Fax:208-944-0488
Practice Address - Street 1:299 ANDERSON RD
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-4927
Practice Address - Country:US
Practice Address - Phone:208-782-4744
Practice Address - Fax:208-906-1554
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist