Provider Demographics
NPI:1801875604
Name:PHYSICAL THERAPY PLUS OF IDAHO PLLC
Entity type:Organization
Organization Name:PHYSICAL THERAPY PLUS OF IDAHO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:PRAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:208-725-5185
Mailing Address - Street 1:PO BOX 2182
Mailing Address - Street 2:180 W 1ST ST #101
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-2182
Mailing Address - Country:US
Mailing Address - Phone:208-725-5185
Mailing Address - Fax:208-725-5192
Practice Address - Street 1:180 W 1ST ST
Practice Address - Street 2:#101
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-725-5185
Practice Address - Fax:208-725-5192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDHCFAT9511OtherBLUE CROSS
ID805993300Medicaid
CB2679OtherRAILROAD MC
ID805993300Medicaid