Provider Demographics
NPI:1104061084
Name:ALTA SPORTS THERAPY
Entity type:Organization
Organization Name:ALTA SPORTS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:FEIG
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:801-944-1219
Mailing Address - Street 1:PO BOX 71403
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-0403
Mailing Address - Country:US
Mailing Address - Phone:801-944-1209
Mailing Address - Fax:
Practice Address - Street 1:GOLDMINER'S DAUGHTER LODGE
Practice Address - Street 2:SUITE 1
Practice Address - City:ALTA
Practice Address - State:UT
Practice Address - Zip Code:84092-8072
Practice Address - Country:US
Practice Address - Phone:801-944-1209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT121600-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty