Basic Information
| Provider Information | |||||||||
| NPI: | 1962035469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RACINE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | DOUGLAS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 E STATE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836165915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089399594 | ||||||||
| FaxNumber: | 2089399828 | ||||||||
| Practice Location | |||||||||
| Address1: | 1618 S MILLENIUM WAY STE 210 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836426457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2088844647 | ||||||||
| FaxNumber: | 2088848984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2020 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT-6627 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.