Basic Information
| Provider Information | |||||||||
| NPI: | 1669812301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOSS | ||||||||
| FirstName: | CALEB | ||||||||
| MiddleName: | JEROME | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8382 N WAYNE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838356028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087580484 | ||||||||
| FaxNumber: | 2084854781 | ||||||||
| Practice Location | |||||||||
| Address1: | 8382 N WAYNE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087580484 | ||||||||
| FaxNumber: | 2084854781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2013 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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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 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.