Basic Information
| Provider Information | |||||||||
| NPI: | 1487630240 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERAPEUTIC ASSOCIATES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TAI SE BOISE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16083 SW UPPER BOONES FERRY RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002198835 | ||||||||
| FaxNumber: | 5034431402 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 S BROADWAY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084339211 | ||||||||
| FaxNumber: | 2084339241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | GIFFORD | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | INFORMATION SYSTEMS DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5034436156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | ID | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1487630240-000 | 05 | ID | MEDICAID | 197670349 | 05 | ID | MEDICAID | 1487630240 | 05 | ID | MEDICAID | 197670349 | 01 | ID | OWCP | OTHER |