Provider Demographics
NPI:1861173247
Name:WALDECK, RILEY D (DPT)
Entity type:Individual
Prefix:
First Name:RILEY
Middle Name:D
Last Name:WALDECK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-901-8477
Mailing Address - Fax:208-629-7529
Practice Address - Street 1:3157 E BARBER VALLEY DR STE 120
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-4770
Practice Address - Country:US
Practice Address - Phone:208-901-8477
Practice Address - Fax:208-629-7529
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT8820225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist