Basic Information
| Provider Information | |||||||||
| NPI: | 1659642775 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSIOONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2834 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838352834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088189263 | ||||||||
| FaxNumber: | 2084854781 | ||||||||
| Practice Location | |||||||||
| Address1: | 8827 N GOVERNMENT WAY UNIT 106 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838358231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087580484 | ||||||||
| FaxNumber: | 2084854781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2012 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | BLACKWELDER | ||||||||
| AuthorizedOfficialFirstName: | TYLER | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2087580484 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 09/21/2020 | ||||||||
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 |
ID Information
| ID | Type | State | Issuer | Description | IDTPID008105 | 05 | ID | MEDICAID |