Provider Demographics
NPI:1265317341
Name:KALLGREN, BRANDON PHOENIX (DPT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:PHOENIX
Last Name:KALLGREN
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 1:198 WHITTIER ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2207
Mailing Address - Country:US
Mailing Address - Phone:208-360-6955
Mailing Address - Fax:
Practice Address - Street 1:3155 CHANNING WAY STE D
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7875
Practice Address - Country:US
Practice Address - Phone:208-973-4170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5171576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist