Provider Demographics
NPI:1871659748
Name:FREGIA RUCKS, KRISTI (PT)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:FREGIA RUCKS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 KENYON RD
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5580
Mailing Address - Country:US
Mailing Address - Phone:715-218-3515
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5814
Practice Address - Country:US
Practice Address - Phone:208-814-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5353-024225100000X
ID5360225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871659748Medicaid
WI40267500Medicaid