Healthcare Provider Details

I. General information

NPI: 1033704101
Provider Name (Legal Business Name): VISTA PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MIDWAY DR
AMMON ID
83406-6799
US

IV. Provider business mailing address

233 S EMERY LN
IDAHO FALLS ID
83401-4674
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-1715
  • Fax:
Mailing address:
  • Phone: 208-529-1715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KEEGAN DAVID PARMER
Title or Position: OWNER
Credential: DPT
Phone: 208-529-1715