Provider Demographics
NPI:1295897213
Name:MYOFASCIAL RELEASE TREATMENT CENTER OF IDAHO LLC
Entity type:Organization
Organization Name:MYOFASCIAL RELEASE TREATMENT CENTER OF IDAHO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNERMEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CHATBURN
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:208-321-7831
Mailing Address - Street 1:1556 S TIMESQUARE LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-8269
Mailing Address - Country:US
Mailing Address - Phone:208-321-7831
Mailing Address - Fax:208-323-7651
Practice Address - Street 1:1556 S TIMESQUARE LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-8269
Practice Address - Country:US
Practice Address - Phone:208-321-7831
Practice Address - Fax:208-323-7651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1377512Medicare PIN