Basic Information
| Provider Information | |||||||||
| NPI: | 1841563335 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ANDREASEN | ||||||||
| FirstName: | ERIC | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 475 CITY STREET | ||||||||
| Address2: | PO BOX 173 | ||||||||
| City: | NEWDALE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084584721 | ||||||||
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| Practice Location | |||||||||
| Address1: | 393 EAST SECOND NORTH | ||||||||
| Address2: | |||||||||
| City: | REXBURG | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083599570 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2012 | ||||||||
| LastUpdateDate: | 02/15/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-1527 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.