Basic Information
| Provider Information | |||||||||
| NPI: | 1346576303 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODENHAMER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 129 | ||||||||
| Address2: | |||||||||
| City: | DRIGGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834220129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532733200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 SKI HILL RD | ||||||||
| Address2: | |||||||||
| City: | DRIGGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834220129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083543128 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2009 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT2609 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1378483 | 01 | ID | GROUP NPI | OTHER |