Provider Demographics
NPI:1063781813
Name:INDEPENDENCE REHAB, LLC
Entity type:Organization
Organization Name:INDEPENDENCE REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-494-0486
Mailing Address - Street 1:5314 RIVER RUN DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5691
Mailing Address - Country:US
Mailing Address - Phone:801-494-0486
Mailing Address - Fax:801-494-0533
Practice Address - Street 1:5314 RIVER RUN DR
Practice Address - Street 2:SUITE 140
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5691
Practice Address - Country:US
Practice Address - Phone:801-494-0486
Practice Address - Fax:801-494-0533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
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
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT60040Medicare UPIN
AZZ140401Medicare UPIN
WAG8882960Medicare UPIN