Provider Demographics
NPI:1629761226
Name:BURCH, GREGARY GRADON (PT)
Entity Type:Individual
Prefix:
First Name:GREGARY
Middle Name:GRADON
Last Name:BURCH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 POLELINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-4904
Mailing Address - Country:US
Mailing Address - Phone:208-242-8617
Mailing Address - Fax:833-608-2470
Practice Address - Street 1:4141 POLELINE RD STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-4904
Practice Address - Country:US
Practice Address - Phone:208-242-8617
Practice Address - Fax:833-608-2470
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-8623225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist