Basic Information
| Provider Information | |||||||||
| NPI: | 1598300824 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINTSUGI PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR STE 150 | ||||||||
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| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 17833 1ST AVE S STE A | ||||||||
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| City: | NORMANDY PARK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981481713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533308518 | ||||||||
| FaxNumber: | 2533308519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2019 | ||||||||
| LastUpdateDate: | 11/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | RILEY | ||||||||
| AuthorizedOfficialFirstName: | CHRISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PT | ||||||||
| AuthorizedOfficialTelephone: | 2533308518 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.