1881738904 NPI number — LOGAN PHYSICAL THERAPY PC

Table of content: (NPI 1881738904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881738904 NPI number — LOGAN PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOGAN PHYSICAL THERAPY PC
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:
1881738904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6518
Provider Second Line Business Mailing Address:
2310 NORTH 400 EAST SUITE C
Provider Business Mailing Address City Name:
NORTH LOGAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84341-6518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-752-5200
Provider Business Mailing Address Fax Number:
435-752-5228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2310 N 400 E
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341-1788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-752-5200
Provider Business Practice Location Address Fax Number:
435-752-5228
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DOUCETTE
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
435-752-5200

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  1162582401 , 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: 326689687024-N0654 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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