Healthcare Provider Details

I. General information

NPI: 1568386860
Provider Name (Legal Business Name): DUSTIN ZACHARY BRADY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WINN DR STE 100
REXBURG ID
83440-5277
US

IV. Provider business mailing address

816 W 60 S
BLACKFOOT ID
83221-6179
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-0174
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8581729
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: