Healthcare Provider Details

I. General information

NPI: 1518705441
Provider Name (Legal Business Name): PALISADE PHYSICAL THERAPY & WELLNESS SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 LEMMON LN
RIGBY ID
83442-4921
US

IV. Provider business mailing address

329 LEMMON LN
RIGBY ID
83442-4921
US

V. Phone/Fax

Practice location:
  • Phone: 208-227-3254
  • Fax:
Mailing address:
  • Phone: 208-227-3254
  • Fax: 208-252-7535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: BRYANT GARDNER
Title or Position: DPT
Credential: PT
Phone: 208-227-3254