Individual
MR. RANDY C SIDWELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, MS, ATC
Contact information
Practice address
333 N 18TH AVE STE D2, POCATELLO, ID 83201-3358
(208) 232-6490
(208) 234-4805
Mailing address
333 N 18TH AVE STE D2, POCATELLO, ID 83201-3358
(208) 232-6490
(208) 234-4805
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PT-1535
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
805846600
—
ID
Enumeration date
02/21/2007
Last updated
03/15/2012
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