NPIMap

Individual provider Active NPI

Bruce J. Wallentine, MPT

  • Physical Therapist
  • Ovid, ID
National Provider Identifier
1023129251
Registry record updated Jul 8, 2007
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical TherapistTaxonomy code 225100000X
License
PT-593 Issued in ID
Practice address
900 Lanark Rd
Ovid, ID 83254-4934
Phone
(208) 945-2900
Fax
(208) 945-2900
NPI assigned
Aug 31, 2006
Last updated
Jul 8, 2007By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Jul 8, 2007

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapist 225100000X PT-593 ID Primary
Physical Therapist 225100000X PT-389 WY
Physical Therapist 225100000X 362968-2401 UT

Addresses

Primary practice location

900 Lanark Rd
Ovid, ID 83254-4934

Mailing address

900 Lanark Rd
Ovid, ID 83254-4934
Phone (208) 945-2900

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
PT-593IDMDPhysical Therapist
362968-2401UTMDPhysical Therapist
PT-389WYMDPhysical Therapist

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156982400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1023129251",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "900 LANARK RD",
            "city": "OVID",
            "state": "ID",
            "postal_code": "832544934",
            "telephone_number": "208-945-2900",
            "fax_number": "208-945-2900"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "900 LANARK RD",
            "city": "OVID",
            "state": "ID",
            "postal_code": "832544934",
            "telephone_number": "208-945-2900",
            "fax_number": "208-945-2900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLENTINE",
        "first_name": "BRUCE",
        "middle_name": "J.",
        "name_prefix": "Mr.",
        "credential": "MPT",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2006-08-31",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "ID",
            "license": "PT-593",
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "WY",
            "license": "PT-389",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "UT",
            "license": "362968-2401",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.