Provider Demographics
NPI:1447009220
Name:MOORE, BENJAMIN THOMAS (DPT, PT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:THOMAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 FALLS AVE E STE 401
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3455
Mailing Address - Country:US
Mailing Address - Phone:208-244-7794
Mailing Address - Fax:208-922-7242
Practice Address - Street 1:445 E CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-1815
Practice Address - Country:US
Practice Address - Phone:208-244-7794
Practice Address - Fax:208-922-7242
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-9025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist