Basic Information
| Provider Information | |||||||||
| NPI: | 1902811789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BEARDIN | ||||||||
| FirstName: | MONTE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084764555 | ||||||||
| FaxNumber: | 2084765385 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084764555 | ||||||||
| FaxNumber: | 2084765385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 10/02/2013 | ||||||||
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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-2292 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 100502784 | 05 | NV | MEDICAID |