Basic Information
| Provider Information | |||||||||
| NPI: | 1760627038 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOUGHEED | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 77 N FISHER PARK WAY | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836164796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089720918 | ||||||||
| FaxNumber: | 8778905617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2008 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | PT-3215 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1760627038 | 05 | ID | MEDICAID |