Basic Information
| Provider Information | |||||||||
| NPI: | 1710953278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTON | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 554 N STEELHEAD WY | ||||||||
| Address2: | #162 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083239747 | ||||||||
| FaxNumber: | 2083239752 | ||||||||
| Practice Location | |||||||||
| Address1: | 554 N STEELHEAD WY | ||||||||
| Address2: | #162 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083239747 | ||||||||
| FaxNumber: | 2083239752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT277 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT277 | 01 | ID | BOARD OF MED | OTHER |