Provider Demographics
NPI:1437671021
Name:S.P.O.R.T. PHYSICAL THERAPY CLINIC
Entity type:Organization
Organization Name:S.P.O.R.T. PHYSICAL THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEIGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-746-0214
Mailing Address - Street 1:3506 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-5511
Mailing Address - Country:US
Mailing Address - Phone:208-746-0214
Mailing Address - Fax:208-746-0948
Practice Address - Street 1:3506 12TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-5511
Practice Address - Country:US
Practice Address - Phone:208-746-0214
Practice Address - Fax:208-746-0948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-14
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806463300Medicaid