Basic Information
| Provider Information | |||||||||
| NPI: | 1356412837 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGH PEAKS PHYSICAL THERAPY P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1612 | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834031612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085252090 | ||||||||
| FaxNumber: | 2085252661 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SKI HILL ROAD | ||||||||
| Address2: | |||||||||
| City: | DRIGGS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834225147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083543128 | ||||||||
| FaxNumber: | 2083543128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | BAUMGARDNER | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2083543128 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 807140100 | 05 | ID | MEDICAID |