Provider Demographics
NPI:1184335184
Name:IDAHO FAMILY PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:IDAHO FAMILY PHYSICAL THERAPY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CONNOR
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, CERTDN
Authorized Official - Phone:425-375-8991
Mailing Address - Street 1:833 CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-7301
Mailing Address - Country:US
Mailing Address - Phone:208-466-0566
Mailing Address - Fax:208-697-5213
Practice Address - Street 1:2422 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6300
Practice Address - Country:US
Practice Address - Phone:425-375-8991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-09
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1235713090Medicaid