=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710858402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN REEVES DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2025
-----------------------------------------------------
Last Update Date | 09/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 711 W NORTH ST STE 1
-----------------------------------------------------
City | GRANGEVILLE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83530-1349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-983-1873
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 488 10TH ST
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-4855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-983-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 8171776
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------