Provider Demographics
NPI:1851889182
Name:BIRK, AMMON BENJAMIN (DPT)
Entity Type:Individual
Prefix:
First Name:AMMON
Middle Name:BENJAMIN
Last Name:BIRK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 BALLARD WAY
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-5162
Mailing Address - Country:US
Mailing Address - Phone:801-874-0479
Mailing Address - Fax:
Practice Address - Street 1:940 BALLARD WAY
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341
Practice Address - Country:US
Practice Address - Phone:801-874-0479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4245225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist