Provider Demographics
NPI:1972171114
Name:LEIFSON, DALLIN ROBERT (PT, DPT)
Entity type:Individual
Prefix:MR
First Name:DALLIN
Middle Name:ROBERT
Last Name:LEIFSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 S STOUT AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3230
Mailing Address - Country:US
Mailing Address - Phone:801-389-6496
Mailing Address - Fax:
Practice Address - Street 1:3345 POTOMAC WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4978
Practice Address - Country:US
Practice Address - Phone:208-233-2248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-7487225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist