Organization
FITNESS FORWARD PHYSICAL THERAPY PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JON CHRISTOPHER MALLAMS PTA (PTA/OWNER)
(208) 424-3999
Entity
Organization
Contact information
Practice address
1775 E 17TH ST STE D, IDAHO FALLS, ID 83404-4902
(208) 243-9999
(208) 243-9999
Mailing address
1775 E 17TH ST STE D, IDAHO FALLS, ID 83404-4902
(208) 243-9999
(208) 243-9999
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PTA-3754
STATE LICENSE
ID
Enumeration date
12/20/2017
Last updated
12/20/2017
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