Provider Demographics
NPI:1902084833
Name:CAMP HIPPO PEDIATRIC THERAPY LLC.
Entity Type:Organization
Organization Name:CAMP HIPPO PEDIATRIC THERAPY LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JAQUES
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:208-782-2267
Mailing Address - Street 1:7 N 600 W
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-5533
Mailing Address - Country:US
Mailing Address - Phone:208-782-2267
Mailing Address - Fax:208-684-9812
Practice Address - Street 1:7 N 600 W
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-5533
Practice Address - Country:US
Practice Address - Phone:208-782-2267
Practice Address - Fax:208-684-9812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-232261QM1300X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID232-OTOtherOT LICENSE