Provider Demographics
NPI:1518560671
Name:IDAHO DIRECT PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:IDAHO DIRECT PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:815-545-3996
Mailing Address - Street 1:1559 N STEVENS DR APT B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3947
Mailing Address - Country:US
Mailing Address - Phone:815-545-3996
Mailing Address - Fax:
Practice Address - Street 1:1559 N STEVENS DR APT B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3947
Practice Address - Country:US
Practice Address - Phone:815-545-3996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy