Organization
CLIFFORD L KIRACOFE PT PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CLIFFORD KIRACOFE (OWNER)
(208) 772-6991
Entity
Organization
Contact information
Practice address
8836 N HESS ST, STE C, HAYDEN, ID 83835-8718
(208) 772-6991
(208) 772-6674
Mailing address
PO BOX 293, HAYDEN, ID 83835-0293
(208) 772-6991
(208) 772-6674
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
1620
MT
225100000X
Physical Therapist
Primary
PT1579
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807136100
—
ID
Enumeration date
07/25/2006
Last updated
06/12/2008
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