Provider Demographics
NPI:1053461533
Name:BONNER PHYSICAL THERAPY P.C.
Entity type:Organization
Organization Name:BONNER PHYSICAL THERAPY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SODORFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-263-5731
Mailing Address - Street 1:1327 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1735
Mailing Address - Country:US
Mailing Address - Phone:208-263-5731
Mailing Address - Fax:208-265-4716
Practice Address - Street 1:1327 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-1735
Practice Address - Country:US
Practice Address - Phone:208-263-5731
Practice Address - Fax:208-265-4716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT0049OtherBLUE CROSS OF IDAHO
ID000010008010OtherREGENCE BLUE SHIELD
ID=========OtherTAX ID
ID1650099Medicare ID - Type UnspecifiedMEDICARE
ID1282480001Medicare NSC