Provider Demographics
NPI:1871331702
Name:SUMMIT PHYSICAL THERAPY
Entity type:Organization
Organization Name:SUMMIT PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:LANGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:208-939-3332
Mailing Address - Street 1:457 S FITNESS PL STE 100
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6568
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:152 N SENECA SPRINGS WAY # 110
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-6037
Practice Address - Country:US
Practice Address - Phone:208-995-2913
Practice Address - Fax:208-995-2659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy