Provider Demographics
NPI:1639901879
Name:BURNS, ROBERT STEPHEN (LMT)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:STEPHEN
Last Name:BURNS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 W SUNNYSIDE RD STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-4644
Mailing Address - Country:US
Mailing Address - Phone:801-635-6437
Mailing Address - Fax:
Practice Address - Street 1:354 W SUNNYSIDE RD STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-4644
Practice Address - Country:US
Practice Address - Phone:801-635-6437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-5171225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty