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General NPI Number Information
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NPI Number | 1265317341
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Entity Type | Individual
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Provider Name | BRANDON PHOENIX KALLGREN DPT
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Gender | Male
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Dates
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Enumeration Date | 08/08/2025
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Last Update Date | 08/08/2025
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Provider Practice Location Address
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Address Line | 3155 CHANNING WAY STE D
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7875
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Country | US
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Telephone | 208-973-4170
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Fax |
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Provider Business Mailing Address
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Address Line | 198 WHITTIER ST
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City | IDAHO FALLS
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State | ID
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Zip | 83402-2207
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Country | US
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Telephone | 208-360-6955
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5171576
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License Number State | ID
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