| Autumn Grove, | |
|
8238 N Government Way, Hayden, ID 83835-5034 | |
| (208) 762-2100 | |
| (208) 762-2101 |
| Full Name | Autumn Grove |
|---|---|
| Gender | Female |
| Speciality | Physical Therapist |
| Location | 8238 N Government Way, Hayden, Idaho |
| Accepts Medicare Assignments | Medicare enrolled and may accept medicare through third-party reassignment. May prescribe medicare part D drugs. |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033596747 | NPI | - | NPPES |
| PT-5390 | Other | ID | IDAHO STATE PHYSICAL THERAPY LICENSE |
| PTL. 0013479 | Other | CO | COLORADO STATE PHYSICAL THERAPY LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2251X0800X | Physical Therapist - Orthopedic | PTL. 0013479 (Colorado) | Secondary |
| 225100000X | Physical Therapist | PT-5390 (Idaho) | Primary |
| Provider Name | Lake City Physical Therapy P A |
|---|---|
| Provider Type | Part B Supplier - Clinic/group Practice |
| Provider Identifiers | NPI Number: 1952521411 PECOS PAC ID: 3678465234 Enrollment ID: O20040503001343 |
| Mailing Address | Practice Location Address |
|---|---|
| Autumn Grove, 8238 N Government Way, Hayden, ID 83835-5034 Ph: (208) 762-2100 | Autumn Grove, 8238 N Government Way, Hayden, ID 83835-5034 Ph: (208) 762-2100 |
Laura Handyside Steininger, DPT Physical Therapist Medicare: Accepting Medicare Assignments Practice Location: 8382 N Wayne Dr Ste 204, Hayden, ID 83835 Phone: 208-719-9071 Fax: 208-719-9073 | |
Erica Lea Chvilicek, P.T. Physical Therapist Medicare: Not Enrolled in Medicare Practice Location: 8257 N Cornerstone Dr, Hayden, ID 83835 Phone: 208-762-0881 | |
Jeremy Albert Dye, M.P.T. Physical Therapist Medicare: Accepting Medicare Assignments Practice Location: 1172 W Hayden Ave, Hayden, ID 83835 Phone: 208-773-8111 Fax: 208-773-8385 | |
Teri Ann Venera, MPT Physical Therapist Medicare: Not Enrolled in Medicare Practice Location: 8382 N Wayne Dr, Hayden, ID 83835 Phone: 208-758-0484 Fax: 208-485-4781 | |
Adam Michael Borg, PT Physical Therapist Medicare: Accepting Medicare Assignments Practice Location: 1172 W Hayden Ave, Hayden, ID 83835 Phone: 208-762-3332 Fax: 208-762-4268 | |
Justin Thomas Kane, PT Physical Therapist Medicare: Accepting Medicare Assignments Practice Location: 1172 W Hayden Ave, Hayden, ID 83835 Phone: 208-762-3332 Fax: 208-762-4268 |