Provider Demographics
NPI:1033704101
Name:VISTA PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:VISTA PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEEGAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PARMER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-529-1715
Mailing Address - Street 1:233 S EMERY LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4674
Mailing Address - Country:US
Mailing Address - Phone:208-529-1715
Mailing Address - Fax:
Practice Address - Street 1:1615 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6799
Practice Address - Country:US
Practice Address - Phone:208-529-1715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty