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General NPI Number Information
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NPI Number | 1750242889
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Entity Type | Organization
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Legal Business Name | PHYSIO SHOP IDAHO LLC
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Dates
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Enumeration Date | 11/19/2025
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 2283 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-317-1736
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Fax |
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Provider Business Mailing Address
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Address Line | 2283 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-317-1736
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST
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Name | TYLER L JOHNSON
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Credential | PT, DPT
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Telephone | 208-317-1736
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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 |
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License Number State |
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