Basic Information
| Provider Information | |||||||||
| NPI: | 1477657468 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 711185 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84171 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019423311 | ||||||||
| FaxNumber: | 8019425955 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 WEST MALLARD DR | ||||||||
| Address2: | A | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084229826 | ||||||||
| FaxNumber: | 2084229855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT458 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 0027023000 | 05 | ID | MEDICAID |