Basic Information
| Provider Information | |||||||||
| NPI: | 1477625283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HIGHLAND PHYSICAL THERAPY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1951 BENCH RD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082372080 | ||||||||
| FaxNumber: | 2082371084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 10/06/2022 | ||||||||
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| AuthorizedOfficialLastName: | SCHWARZE | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2082372080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPT | ||||||||
| NPICertificationDate: | 10/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | TD478 | 01 | ID | MICHAEL OTTO | OTHER | TD480 | 01 | ID | JONI VAUGHN POWELL | OTHER | TD481 | 01 | ID | DALE WHEELWRIGHT | OTHER | 000010155854 | 01 | ID | MICHAEL OTTO | OTHER | 1356304737 | 01 | ID | DALE WHEELWRIGHT NPI | OTHER | 1962465344 | 01 | ID | JONI VAUGHN POWELL NPI | OTHER | 000010155857 | 01 | ID | JONI VAUGHN POWELL | OTHER | T9325 | 01 | ID | HIGHLAND PHYSICAL THERAPY | OTHER | 805478000 | 05 | ID | MEDICAID | 000010155953 | 01 | ID | DALE WHEELWRIGHT | OTHER | 002682600 | 05 | ID | MEDICAID | 1558324590 | 01 | ID | MICHAEL OTTO NPI | OTHER | 806464000 | 05 | ID | MEDICAID |