Basic Information
| Provider Information | |||||||||
| NPI: | 1114374741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | REAGAN | ||||||||
| MiddleName: | RONALD | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1411 FALLS AVE E STE 401 | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089699945 | ||||||||
| FaxNumber: | 2089440488 | ||||||||
| Practice Location | |||||||||
| Address1: | 931 CENTER ST W STE C | ||||||||
| Address2: | |||||||||
| City: | KIMBERLY | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833415326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084239999 | ||||||||
| FaxNumber: | 2084239998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2016 | ||||||||
| LastUpdateDate: | 05/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 7832781-2401 | UT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 4532 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.