Provider Demographics
NPI:1518705441
Name:PALISADE PHYSICAL THERAPY & WELLNESS SERVICES
Entity type:Organization
Organization Name:PALISADE PHYSICAL THERAPY & WELLNESS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTICING THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:208-569-5182
Mailing Address - Street 1:3649 E GAMPLE AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4542
Mailing Address - Country:US
Mailing Address - Phone:208-569-5182
Mailing Address - Fax:
Practice Address - Street 1:3649 E GAMPLE AVE APT 4
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4542
Practice Address - Country:US
Practice Address - Phone:208-569-5182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-16
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty