Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | PT - 1742 | ID |
NPI | 1023396884 |
---|---|
Provider Name | Emily Renovitch |
First Address | Driggs, ID 83422 |
Second Address | Driggs, ID 83422-5095 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/07/2011 |
Last Update Date | 28/07/2011 |