Provider Demographics
NPI:1861254278
Name:DUPONT WELLNESS PLLC
Entity type:Organization
Organization Name:DUPONT WELLNESS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPONT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-570-3004
Mailing Address - Street 1:1460 E SHENANDOAH DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6657
Mailing Address - Country:US
Mailing Address - Phone:208-570-3004
Mailing Address - Fax:208-252-6297
Practice Address - Street 1:1460 E SHENANDOAH DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6657
Practice Address - Country:US
Practice Address - Phone:208-570-3004
Practice Address - Fax:208-252-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty