1053573469 NPI number — PHYSICAL THERAPY AND SPORTS MEDICINE LLC

Table of content: (NPI 1053573469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053573469 NPI number — PHYSICAL THERAPY AND SPORTS MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICAL THERAPY AND SPORTS MEDICINE LLC
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:
1053573469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1868 N. 1200 W.
Provider Second Line Business Mailing Address:
STE #A
Provider Business Mailing Address City Name:
LAYTON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84041-1937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-728-4624
Provider Business Mailing Address Fax Number:
801-776-3087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4883 W. OLD HIGHWAY RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN GREEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-728-4624
Provider Business Practice Location Address Fax Number:
801-776-3087
Provider Enumeration Date:
06/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KERBS
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PROVIDER/OWNER
Authorized Official Telephone Number:
801-728-4624

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  274721 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)





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