1629259189 NPI number — PROFESSIONAL THERAPY AND REHABILITATION LLC

Table of content: (NPI 1629259189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629259189 NPI number — PROFESSIONAL THERAPY AND REHABILITATION LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL THERAPY AND REHABILITATION 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:
6
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:
1629259189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 S 400 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPANISH FORK
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84660-2053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-798-1626
Provider Business Mailing Address Fax Number:
801-798-1236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 S 400 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPANISH FORK
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84660-2053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-798-1626
Provider Business Practice Location Address Fax Number:
801-798-1236
Provider Enumeration Date:
11/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BUDGE
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER/PHYSICAL THERAPIST
Authorized Official Telephone Number:
801-798-1626

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: QM0000076331 . This is a "ALTIUS HEALTH PLANS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: PRA03496 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 695780 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com