Basic Information
| Provider Information | |||||||||
| NPI: | 1558828020 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANDPOINT PHYSICAL THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 N DIVISION AVE | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838648268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082650610 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 N DIVISION AVE | ||||||||
| Address2: | |||||||||
| City: | SANDPOINT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838648268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082650610 | ||||||||
| FaxNumber: | 2082659192 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2019 | ||||||||
| LastUpdateDate: | 02/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | THOME | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | ELIZABETH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2103938090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1215237201 | 05 | ID | MEDICAID |