Healthcare Provider Details

I. General information

NPI: 1003721408
Provider Name (Legal Business Name): WALLACE LEONARD ARAVE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

PO BOX 262
SHELLEY ID
83274-0262
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-7999
  • Fax: 208-529-7082
Mailing address:
  • Phone: 208-529-7999
  • Fax: 208-520-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1828
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: