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General NPI Number Information
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NPI Number | 1518560671
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Entity Type | Organization
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Legal Business Name | IDAHO DIRECT PHYSICAL THERAPY, PLLC
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Dates
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Enumeration Date | 11/19/2020
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Last Update Date | 11/19/2020
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Provider Practice Location Address
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Address Line | 1559 N STEVENS DR APT B
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3947
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Country | US
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Telephone | 815-545-3996
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Fax |
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Provider Business Mailing Address
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Address Line | 1559 N STEVENS DR APT B
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City | IDAHO FALLS
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State | ID
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Zip | 83401-3947
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Country | US
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Telephone | 815-545-3996
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TYLER J BURKE
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Credential | DPT
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Telephone | 815-545-3996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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