Provider Demographics
NPI:1184707911
Name:POCATELLO PHYSICAL THERAPY CLINIC PA
Entity type:Organization
Organization Name:POCATELLO PHYSICAL THERAPY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DES FOSSES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-233-4800
Mailing Address - Street 1:PO BOX 2844
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83206-2844
Mailing Address - Country:US
Mailing Address - Phone:208-233-4800
Mailing Address - Fax:208-233-4887
Practice Address - Street 1:1033 W QUINN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-2425
Practice Address - Country:US
Practice Address - Phone:208-233-4800
Practice Address - Fax:208-233-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002463600Medicaid
ID000010026861OtherBLUE SHIELD
IDT0296OtherBLUE CROSS
ID002463600Medicaid