1780731992 NPI number — PEAK PERFORMANCE PHYSICAL THERAPY AND FITNESS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780731992 NPI number — PEAK PERFORMANCE PHYSICAL THERAPY AND FITNESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEAK PERFORMANCE PHYSICAL THERAPY AND FITNESS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780731992
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOUNTIFUL
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84011-0307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-700-6907
Provider Business Mailing Address Fax Number:
801-294-6917

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COALVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-654-3719
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WADE
Authorized Official First Name:
RODNEY
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
435-654-3719

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5327836-2401 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 529791445001 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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