Provider Demographics
NPI:1821628645
Name:ELLIS PHYSICAL THERAPY AND ASSOCIATES LLC
Entity Type:Organization
Organization Name:ELLIS PHYSICAL THERAPY AND ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-523-8879
Mailing Address - Street 1:3100 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8310
Mailing Address - Country:US
Mailing Address - Phone:208-523-8879
Mailing Address - Fax:
Practice Address - Street 1:3100 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8310
Practice Address - Country:US
Practice Address - Phone:208-523-8879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy