Provider Demographics
NPI:1548808637
Name:POCATELLO PHYSICAL THERAPY
Entity type:Organization
Organization Name:POCATELLO PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-232-6490
Mailing Address - Street 1:333 N 18TH AVE STE D2
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3358
Mailing Address - Country:US
Mailing Address - Phone:208-232-6490
Mailing Address - Fax:208-234-4805
Practice Address - Street 1:333 N 18TH AVE STE D2
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3358
Practice Address - Country:US
Practice Address - Phone:208-232-6490
Practice Address - Fax:208-234-4805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty