Provider Demographics
NPI:1124263728
Name:FAST TRACK PHYSICAL THERAPY AND SPORTS MEDICINE, PLLC
Entity type:Organization
Organization Name:FAST TRACK PHYSICAL THERAPY AND SPORTS MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MS, ATC
Authorized Official - Phone:801-649-4690
Mailing Address - Street 1:6717 SOUTH 900 EAST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047
Mailing Address - Country:US
Mailing Address - Phone:801-649-4690
Mailing Address - Fax:801-984-4011
Practice Address - Street 1:6717 SOUTH 900 EAST
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047
Practice Address - Country:US
Practice Address - Phone:801-649-4690
Practice Address - Fax:801-984-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-10
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6006997-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty