Individual
BRAD ARCHIBALD
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OTR
Contact information
Practice address
4893 CAMAS CREEK CIR., IONA, ID 83427
(208) 351-0651
(208) 528-0989
Mailing address
PO BOX 354, IONA, ID 83427-0354
(208) 351-0651
(208) 528-0989
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
OT-637
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
TA930
BLUE CROSS GROUP #
ID
01
—
W0996
BLUE CROSS PROVIDERNUMBER
ID
Enumeration date
04/03/2007
Last updated
07/08/2007
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