1992874440 NPI number — BEAR LAKE PHYSICAL AND SPORTS THERAPY PC

Table of content: (NPI 1992874440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992874440 NPI number — BEAR LAKE PHYSICAL AND SPORTS THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAR LAKE PHYSICAL AND SPORTS 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:
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:
1992874440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 276
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDEN CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84028-0276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-946-2777
Provider Business Mailing Address Fax Number:
435-946-9777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 N 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83254-1086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-847-1342
Provider Business Practice Location Address Fax Number:
435-744-6066
Provider Enumeration Date:
11/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JARMAN
Authorized Official First Name:
RUTHANN
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
435-946-2777

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT1256 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com