Basic Information
| Provider Information | |||||||||
| NPI: | 1447383625 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PINNACLE PHYSICAL THERAPY AND SPORTS MEDICINE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SUMMIT REHABILITATION ASSOCIATES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1590 E POLSTON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087774242 | ||||||||
| FaxNumber: | 2087774020 | ||||||||
| Practice Location | |||||||||
| Address1: | 1590 E POLSTON AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087774242 | ||||||||
| FaxNumber: | 2087774020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 09/11/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BENGTSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087774242 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.P.T. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000010160541 | 01 | ID | REGENCE BLUESHIELD | OTHER | T9333 | 01 | ID | BLUE CROSS | OTHER |