Provider Demographics
NPI:1881100261
Name:FITNESS FORWARD PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:FITNESS FORWARD PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PTA/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:MALLAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:208-424-3999
Mailing Address - Street 1:1775 E 17TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4902
Mailing Address - Country:US
Mailing Address - Phone:208-243-9999
Mailing Address - Fax:208-243-9999
Practice Address - Street 1:1775 E 17TH ST STE D
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4902
Practice Address - Country:US
Practice Address - Phone:208-243-9999
Practice Address - Fax:208-243-9999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPTA-3754OtherSTATE LICENSE