Provider Demographics
NPI:1063429793
Name:AMV MOUNTAIN LAND LC
Entity type:Organization
Organization Name:AMV MOUNTAIN LAND LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:801-942-3311
Mailing Address - Street 1:PO BOX 711185
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171
Mailing Address - Country:US
Mailing Address - Phone:801-942-3311
Mailing Address - Fax:801-942-5955
Practice Address - Street 1:355 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KANAB
Practice Address - State:UT
Practice Address - Zip Code:84741
Practice Address - Country:US
Practice Address - Phone:435-644-4199
Practice Address - Fax:435-644-4141
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOUNTAIN LAND REHABILITATION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-02
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
466502Medicare ID - Type Unspecified